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EMERGENCY  SURGERY 
SLUSS 


THE  LEATHER  BOUND  SERIES 

OF 

MEDICAL   MANUALS 

HUGHES.  Compend  of  the  Practice  of  Medicine.  Tenth 
Edition.  By  Daniel  E.  Hughes,  M.  D.,  late  Chief  Resident 
Physician,  Philadelphia  Hospital,  Revised  by  R.  J.  E.  Scott, 
M.  A.,  B.  C,  L.,  M.  D.,  x^ttending  Physician  to  the  "Demilt 
Dispensary;  Editor  of  the  2nd  Edition  of  Gould  and  Pyle's 
"  Cyclopedia  of  Medicine  and  Surgery,"  etc.  With  Illustra- 
tions. xviii-f-878  pages.  Flexible  Leather,  Gilt  Edges,  Round 
Corners.  $2.50 

KYLE.  Manual  of  Diseases  of  the  Ear,  Nose  and  Throat. 
Second  Edition.  By  John  Johnson  Kyle,  B.  S.,  M.  D.,  Pro- 
fessor of  Otology,  Rhinology  and  Laryngology  in  the  Univer- 
sity of  Southern  California;  Member  of  the  American  Laryn- 
gological,  Rhinological  and  Otological  Society,  With  169  Il- 
lustrations,    Flexible  Leather,  Gilt  Edges,  Round  Corners, 

$3.00 

SLUSS.  Emergency  Surgery.  Third  Edition.  By  John  W. 
Sluss,  A.  M.,  M.  D.,  Associate  Professor  of  Surgery,  Indiana 
University  School  of  Medicine;  Ex-Superintendent  Indianapolis 
City  Hospital;  Surgeon  to  the  Indianapolis  City  Hospital. 
With  685  Illustrations,  xvii-l-828  pages.  i2mo.  Flexible 
Leather,  Gilt  Edges,  Round  Corners.  $4.00 

THAYER.  Manual  of  Pathology.  131  Illustrations.  General 
and  Special.  By  A.  E.  Thayer,  M.  D.,  Professor  of  Pathology, 
University  of  Texas;  formerly  Assistant  Instructor  in  Path- 
ology, Cornell  Medical  School.  With  131  Illustrations.  711 
pages.     i2mo.     Flexible  Leather,  Gilt  Edges,  Round  Corners. 

$2.50 

*  *  *  Other  Volumes  in  Preparation. 

P.     BLAKISTON^S     SON    &    CO. 

Publishers         :         :         PHILADELPHIA 


EMERGENCY  SURGERY 


BY 


JOHN  W.  SLUSS,  A.M.,  M.D. 

ASSOCIATE  PROFESSOR  OF  SURGERY,   INDIANA    UNIVERSITY    SCHOOL 
OF  medicine;   ex-superintendent   INDIANAPOLIS   CITY   HOS- 
PITAL;  SURGEON  TO  THE  CITY  HOSPITAL 


THIRD  EDITION,  REVISED  AND  ENLARGED 

WITH  685  ILLUSTRATIONS 

SOME  OF  WHICH  ARE  PRINTED  IN  COLORS 


PHILADELPHIA 

P.   BLAKISTON'S   SON   &   CO, 

1012  WALNUT  STREET 


L 


< 


Copyright,  1915,  by  P.  Blakiston's  Sox  &  Co. 


THE. MAPLE. PRESS. YORK. PA 


DEDICATION 

TO  MY  PRECEPTOR,  DR.  E.  B.  EVANS,  TYPE  AND  EXEMPLAR  OF 

GENERAL  PRACTITIONERS,  IN  MEMORY  OF  DAYS  SPENT 

TOGETHER,  THIS  LITTLE  WORK  IS  INSCRIBED 


PREFACE  TO  THE  THIRD  EDITION 


The  present  revision  of  this  volume  has  adhered  to  the  aim  of 
former  editions  to  present  general  principles  concisely,  and  prac- 
tical details  amply — in  short  to  make  a  book  useful  to  the  general 
practitioner  in  the  surgical  phase  of  his  daily  routine. 

Each  subject  has  been  carefully  revised.  The  text  on  Fractures 
has  been  greatly  increased,  consonant  with  the  new  interest  to  the 
profession  generally  which  this  subject  has  acquired  in  recent 
years. 

The  chapter  on  Military  Surgery  has  been  entirely  rewritten  in 
conformity  with  the  surgical  experiences  of  this  latest  and  greatest 
war.  A  number  of  illustrations  borrowed  from  the  British  Journal 
of  Surgery  and  other  sources  are  included. 

The  Technique  of  the  emergency  interventions  will  be  found 
to  coincide  with  the  best  practice  of  the  present  time.  Finally 
the  hope  is  expressed  that  the  volume  will  continue,  as  in  the 
past,  to  find  favor  with  the  medical  public. 

J.  w.  s. 


vn 


PREFACE  TO  SECOND  EDITION 


The  fact  that  the  first  edition  of  this  book  was  sold  out  within  one 
year  is  particularly  gratifying  to  the  author  because  it  indicates  that 
the  results  of  his  effort  to  make  a  useful  and  practical  book  have  met 
with  the  approval  of  the  profession. 

In  preparing  this  second  edition  of  the  "Emergency  Surgery  "  the 
effort  has  been  to  profit  by  the  suggestions  and  criticisms  of  the 
various  reviewers  of  the  first.  It  is  hoped,  in  consequence,  that  its 
usefulness  has  been  increased  and  that  it  will  continue  to  find  favor 
with  its  readers. 

A  new  chapter  on  the  general  technic  of  Laparotomy  has  been 
added;  each  subject  has  been  carefully  reviewed;  and  in  many  in- 
stances new  matter  incorporated..  Thus,  for  example,  Spinal  Anes- 
thesia is  described  in  detail  and  Subphrenic  Abscess  and  Pericardi- 
otomy more  fully  considered. 

Dr.  Helen  Knabe  has  contributed  some  new  illustrations,  and 
the  skiagrams  are  the  work  of  Dr.  Albert  M.  Cole,  of  Indianapolis, 
to  whom  thanks  are  due. 

J.  W.  S. 


vni 


PREFACE  TO  THE  FIRST  EDITION 


Tms  is  a  Surgery  for  the  general  practitioner;  written  not  to 
instruct  his  leisure  hour,  but  in  the  hope  some  time  to  serve  as  a 
guide  out  of  uncertainty  in  a  time  of  stress.  Its  merits  and  demerits 
should  be  reckoned  from  that  point  of  view  alone.  If,  occasionally, 
the  form  of  expression  seems  dogmatic,  it  merely  comports  with  the 
constant  aim  to  be  practical;  certainly  that  aim  has  denied  any  place 
to  theoretical  discussions  and  has  curtailed  reference  to  the  various 
views  of  recognized  authority.  An  absence  of  bibliography,  it  is 
hoped,  therefore,  will  not  be  regarded  as  discourtesy  to  the  many 
writers,  teachers,  and  practitioners  whose  ideas  have  been  so  freely 
appropriated. 

Among  the  text-books  more  constantly  consulted  are  Senn's 
Practical  Surgery,  The  American  Text-book  of  Surgery,  Walsham's 
Surgery,  Treves'  Operative  Surgery,  Lejars'  Chirurgie  d'Urgence, 
Veau's  Chirurgie  d'Urgence  et  Pratique  Courante,  Von  Bergmann's 
Chirurgie,  and  Binnie's  Operative  Surgery. 

The  Annals  of  Surgery,  the  American  Journal  of  Surgery,  the- 
International  Journal  of  Surgery,  and  the  Journal  of  the  American 
Medical  Association  have  been  prolific  sources  of  information. 

For  advice  and  aid  in  many  ways  in  the  preparation  of  this  book, 
special  thanks  are  due  Drs.  John  J.  Kyle,  James  H.  Ford,  A.  W. 
Brayton,  and  Gustav  Bergener.  The  original  illustrations  are  the 
work  of  Dr.  Helen  Knabe. 

To  the  publishers,  through  whose  counsel  and  patient  criticism  the 
book  has  grown  into  its  present  form,  a  grateful  appreciation  is  to  be 
expressed. 

J.  W.  S. 


IX 


CONTENTS 

PART  I 

CHAPTER  I 

Page 

The    General    Practitioner    as    ax    Emergency    Surgeon:     His 
Duties  AND  Responsibility:    Equipment '. i 

CHAPTER  II 
Emergency  Antisepsis.     Operation  in  a  Private  House   ....       6 

CHAPTER  III 
Anesthesia 12 

CHAPTER  IV 
Sutures;  Methods  and  Materials 25 

CHAPTER  V 
Drainage 32 

CHAPTER  VI 
Dressings,  Bandages,  Splints 35 

CHAPTER  VII 

Shock 52 

CHAPTER  VIII 
Hemorrhage 57 

CHAPTER  IX 

Wounds:    General  Principles Ji 

xi 


Xll  CONTENTS 

CHAPTER  X 

Page 

Wounds  of  Special  Regions 8i 

CHAPTER  XI 
Injuries  to  the  Trunk no 

CHAPTER  XII 
Gunshot  and  Other  Wounds  in  Military  Practice 133 

CHAPTER  XIII 
Gunshot  Wounds  in  Civil  Practice 186 

CHAPTER  XIV 
Fractures  of  the  Extremities 200 

CHAPTER  XV 
Compound  Fractures 283 

CHAPTER  XVI 
Fractures  of  the  Clavicle,  Scapula,  Ribs,  Spine,  Pelvis 290 

CHAPTER  XVII 
Fractures    of  the  Skull  and  of    the  Bones  of  the  Face  ....   299 

CHAPTER  XVIII 
Injuries  to  Joints 312 

CHAPTER  XIX 
Injury  and  Repair  of  Tendons , 347 

CHAPTER  XX 
Injury  and  Repair  of  Nerves 357 

CHAPTER  XXI 
Abscess 375 

CHAPTER  XXII 
Philegmon:     Acute  Spreading  Infections 421 


CONTENTS  Xlll 

CHAPTER  XXIII 

Page 

Acute  Osteomyelitis 432 

CHAPTER  XXIV 
Septic  Arthritis 440 

CHAPTER  XXV 
Foreign  Bodies 451 

CHAPTER  XXVI 
Burns,  Scalds,  and  Frost-bite 468 

PART  II 

CHAPTER  I 
Tracheotomy,  Laryngotomy,  Esophagotomy   477 

CHAPTER  II 

Urgent  Thoracotomy.  Repair  of  Injury  to  the  Lungs.  Repair 
OF  Injury  to  the  Pericardium.  Repair  of  Injury  to  the  Heart. 
Puncture  of  the  Pericardium.     Pericardiotomy 488 

CHAPTER  III 
Empyema — Purulent  Pleurisy 502 

CHAPTER  IV 
Urgent  Craniectomy;  Trephining 510 

CHAPTER  V 
Mastoid  Abscess $22 

CHAPTER  VI 
General  Technic  of  Laparotomy. 530 

CHAPTER  VII 
Laparotomy  for  Traumatism 537 

CHAPTER  VIII 
Appendicitis;  Appendicial  Abscess;  Purulent  Peritonitis     .    .    .   557 


XIV  CONTENTS 

CHAPTER  IX 

Page 

Acute  Intestinal  Obstruction 57 y 

CHAPTER  X 
Artificial  Anus;  Temporary,  Permanent 589 

CHAPTER  XI 
Strangulated  Hernia 598 

CHAPTER  XII 

Radical  Cure  of  Inguinal  Hernia 632 

CHAPTER  XIII 
Radical  Cure  of  Femoral  Hernia 643 

CHAPTER  XIV 
Enterectomy.     Intestinal  Anastomosis 650 

CHAPTER  XV 
Imperforate  Anus 662 

CHAPTER  XVI 

Torsion  of  the  Pedicle  of  Ovarian  or  Uterine  Tumors;  of  the 
Spermatic  Cord;  of  the  Pedicle  of  the  Spleen;  of  the  Omentum.  667 

CHAPTER  XVII 
Rupture  and  Hemorrhage  of  Tubal  Pregnancy 675 

CHAPTER  XVIII 
Cesarean  Section 682 

CHAPTER  XIX 
Rupture  of  the  Urethra 686 

CHAPTER  XX 

Acute    Retention;     Catheterization;    Suprapubic    Puncture; 
Cystotomy;  Urinary  Infiltration      698 

CHAPTER  XXI 
Suture  and  Ligation  of  Arteries 717 


CONTENTS  XV 

CHAPTER  XXII 

Page 

Practical  Amputations 728 

CHAPTER  XXIII 

Dilation  of  the  Sphincter  Ani;  Operation  for  Piles;  Operation 
FOR  Anal  Fistula 783 

CHAPTER  XXIV 

Phimosis;  Paraphimosis;  Circumcision;  Hydrocele;  Castration  790 

CHAPTER  XXV 

Ingrowing  Toe-nail 801 

CHAPTER  XXVI 

Removal  of  Saiall  Tumors 804 

CHAPTER  XXVII 

Skin  Grafting 807 

Index 813-828 


EMERGENCY  SURGERY 


CHAPTER  I 


THE   GENERAL   PRACTITIONER  AS   AN   EMERGENCY 
SURGEON:  HIS    DUTIES    AND    RESPONSIBILITY. 

EQUIPMENT 

Surgery  is  no  longer  reserved  to  the  elect  few.  That  its  beneficence 
shall  be  denied  a  place  in  every  practitioner's  art  is  repugnant  to  the 
spirit  of  the  times.  Modern  life  is  complex:  every  profession  and 
every  calling  has  its  specific  duty  to  perform.  Whether  the  medical 
profession  shall  continue  to  play  nobly  its  large  part  in  the  social 
drama  depends  upon  the  general  practitioner.  The  hope  of  the 
profession  rests  in  him.  But  there  is  a  price  to  pay  the  age  for  high 
respect.  That  price  to  the  medical  profession  is  nothing  less  than  the 
fulfillment  of  its  therapeutic  promise  and  realization  of  its  surgical 
opportunity.  The  opportunity  is  golden;  for,  with  the  wonderful 
improvements  in  surgical  technic,  the  field  of  emergency  surgery, 
that  is  to  say,  the  indication  for  immediate  intervention,  has  been 
remarkably  broadened  and  the  time  finds  the  public  singularly  favor- 
able to  that  form  of  relief. 

The  "horror  of  the  knife,"  of  all  that  pertains  to  surgery,  has 
become  a  tradition,  like  the  practice  which  gave  it  birth.  Indeed, 
the  public  is  trained  to  expect  that,  in  the  face  of  grave  emergencies, 
the  practitioner  will  do  something  effective;  however  serious  the  re- 
quired intervention  may  be,  if  it  but  offers  hope,  the  doctor  is  expected 
to  act..  Our  predecessors — even  those  able  and  willing— of  ten  found 
their  hands  tied  under  such  circumstances  by  the  ruling  policy  of 
"  let  alone  and  let  die."  It  is  a  part  of  their  glory  that  they  conceived, 
planned,  and  attempted  in  the  face  of  tremendous  obstacles,  most  of 
the  interventions  of  urgency  which  are  current  to-day. 


2         THE   GENERAL   PRACTITIONER   AS   AN   EMERGENCY   SURGEON 

The  surgical  opportunity,  then,  of  the  general  practitioner  is  clear, 
and^his  duty  as  well.  The  professional  spirit,  the  humanities,  his 
conscience,  make  it  incumbent  upon  him  to  know  and  act.  This 
he  must  do  or  drop  to  the  rear  in  the  march  of  progress,  which  does 
not  halt  for  the  timid  or  unwilling. 

But  the  task  imposed  is  heavy,  the  responsibility  large;  for  the  gen- 
eral practitioner  often  finds  himself  isolated,  remote  from  special 
counsel,  perhaps  compelled  to  act  alone.  That  he  does  not  always 
rise  to  the  surgical  emergency  and  do  all  that  he  might  do  even  under 
unfavorable  circumstances,  may  often  be  laid  in  large  part  at  the  door 
of  his  training.  He  knows  often  what  he  ought  to  do,  yet  knows  not 
how  to  do  it.  Happily  the  courses  of  instruction  are  now  generally 
planned  to  do  away  with  this  strange  antithesis  between  theory  and 
practice:  a  theory,  modern,  scientific,  positive;  a  practice,  as  Lejars 
says,  still  often  full  of  error  and  based  on  empiricism  age-old. 

But  this  must  not  be;  for,  now  that  the  indications  for  operation  are 
exactly  defined  and  one's  duty  obvious,  vague  conception  of  an  opera- 
tion as  something  far  away  and  desperate,  must  give  way  to  clear 
notions  of  the  resources  of  surgery,  of  surgical  therapeusis.  Every 
doctor  must  familiarize  himself  with  the  technic  of  interventions 
which  he  must  undertake  at  times,  if  he  is  not  to  be  inexcusably  re- 
miss in  an  almost  sacred  duty. 

Surgery  in  one  respect  is  a  handicraft,  and  as  such  requires  its 
certain  tools  of  first  necessity.  If,  as  has  been  said,  emergency  sur- 
gery always  comes  in  the  nature  of  a  surprise,  then  the  surprise  will  at 
least  be  less  complete  if  one  has  an  equipment  and  has  it  prepared. 

Every  doctor  should  have  an  emergency  bag  supplied  with  mate- 
rials: hand  brushes,  soap,  a  fountain  syringe,  hypodermic  syringe, 
catheters,  flasks  of  alcohol,  ether,  chloroform  and  carbolic  acid, 
bichloride  tablets,  a  package  of  sterile  compresses,  sutures,  bandages, 
a  box  of  plaster  of  Paris,  and  certain  instruments. 

Hand  Brushes. — These  are  almost  indispensable  for  emergency  sur- 
gery. They  should  be  kept  well  wrapped  and  should  be  cleansed 
with  soap  and  hot  water  and  sterilized  by  boiling  for  one  minute  before 
using.  New  brushes  should  be  boiled  in  soda  solution  for  five  to 
ten  minutes.  If  brushes  are  lacking,  one  may  scrub  the  hands  and 
the  field  of  operation  with  sterile  gauze.     In  the  hospital  where  the 


ANTISEPTICS  3 

cleansing  at  the  time  of  operation  has  been  preceded  by  another  dis- 
infection, gauze  may  be  used  to  the  exclusion  of  the  hand  brush. 

Fountain  Syringe  or  Irrigator. — One  may  use  the  full  rubber  out- 
fit or,  what  is  better,  a  porcelain  container  and  a  long  rubber  tube 
with  glass  nozzles.  It  is  absolutely  essential  that  the  whole  be  steril- 
ized by  boiling.  It  is  nonsense  to  sterilize,  as  is  often  done,  the 
cannula?  and  container,  and  neglect  the  tube.  The  glass  nozzles  are 
likely  to  be  broken  if  plunged  directly  into  boiling  water  or  if  cooled 
too  rapidly.  If  the  porcelain  container  is  used,  it  may  be  boiled  and 
then  singed  with  burning  alcohol.  It  takes  up  but  little  room  in  the 
bag,  and  the  tube  and  nozzles  may  be  wrapped  up  and  packed  in  it 
and  the  whole  wrapped  and  kept  clean  and  dry.  This  outfit  is  al- 
most indispensable,  for  in  many  emergencies  the  only  adequate  treat- 
ment is  by  hypodermoclysis  or  intravenous  infusion. 

The  Antiseptics. — The  alcohol  must  be  kept  in  a  well  stopped  flask 
and  the  carbolic  acid  or  lysol,  also.  The  bichloride  may  be  in  the 
form  of  tablets,  so  that  the  strength  of  a  solution  may  be  readily 
calculated.  The  most  commonly  employed  is  the  formula  contain- 
ing mercury  bichloride  7.3  gr.,  citric  acid  3.8  gr.  This  tablet  in  i 
quart  of  water  makes  a  i  to  2000  solution,  which  is  as  strong  as  need 
be  used.  One  to  3  pints  makes  a  i  to  3000  solution,  and  so  on. 
Instead  of  the  tablets,  one  may  keep  a  concentrated  solution  of  bi- 
chloride in  alcohol. 

Bichloride  of  mercury,  Sj* 

Alcohol,  5j- 

One  teaspoonful  to  a  quart  of  water  makes  a  i  to  2000  solution; 

One  teaspoonful  to  3  pints,  i  to  3000,  etc. 

Instead  of  the  bichloride,  the  biniodide  of  mercury,  i  to  4000  may 
be  used. 

Iodine  grows  constantly  in  favor  in  spite  of  certain  drawbacks.  A 
four  ounce  vial  of  the  tincture  supplies  for  many  sterilizations.  Its 
stain  on  the  hands  and  linens  may  be  remov^  by  moistening  with 
ammonia  or  solution  of  hyposulphite  of  sodium. 

Anesthetics. — One  should  keep  on  hand  at  least  one  pint  of  ether 
and  four  to  six  ounces  of  chloroform.  Cocaine  for  local  anesthesia 
is  best  kept  in  tablet  form  and  the  solutions  made  extemporaneously. 


4        THE   GENERAL   PRACTITIONER   AS    AN   EMERGENCY   SURGEON 

For  example,  212-grain  tablets  of  cocaine  to  i  teaspoonful  of  sterile 
water  makes  a  2  per  cent,  solution;  4H-grain  tablets  of  a  tea- 
spoonful  of  water  makes  a  4  per  cent,  solution;  ioj2-grain  tablets, 
a  10  per  cent,  solution.  This  is  not  exact,  of  course,  but  furnishes  a 
good  working  rule  for  the  emergency.  Novocaine  is  less  dangerous 
than  cocaine  and  in  ^2  or  i  per  cent,  solutions  may  be  used  in  large 
quantity  and  with  excellent  effect.  Ethyl  chloride  for  local  freez- 
ing is  put  up  in  small  containers  convenient  for  the  emergency 
bag. 

Sterile  Gauze. — Too  frequently  the  practitioner  commits  the  error 
of  depending  upon  absorbent  cotton  for  his  sponges  and  compresses. 
Absorbent  cotton,  as  found  on  the  market,  is  scarcely  ever  aseptic. 
Even  so,  it  is  almost  certain  to  be  contaminated  in  getting  it  out 
of  the  package.  A  supply  of  sterile  gauze  is  one  of  the  best  means  of 
promoting  an  aseptic  operation.  It  should  be  kept  in  a  hermetically 
sealed  package  of  metal  or  glass. 

In  lieu  of  the  gauze  compresses  ready  sterilized,  one  may  carry  a 
supply  of  ordinary  gauze  which  can  be  cut  into  appropriate  sizes,  and 
sterilized  at  the  time  of  operation.  It  is  a  good  idea  to  cut  two  sizes; 
a  small  for  compresses  and  wipers,  a  larger  to  cover  the  field  of 
operation.  All  these  pieces  should  be  folded  once  and  the  borders 
hemmed.  A  ball  of  cotton  may  be  hemmed  in  between  the  layers, 
which  makes  a  still  better  sponge.  The  compressed  package  of 
gauze  as  supplied  by  Borroughs  and  Welcome  is  especially  appro- 
priate to  the  small  emergency  bag.  Once  accustomed  to  its  ase  it 
seems  almost  indispensable. 

Sutures  atid  Ligatures.— li  these  materials  are  not  already  sterilized 
and  in  a  special  package  or  container,  such  as  a  sealed  tube  of 
alcohol,  catgut  must  be  ruled  out,  for  its  preparation  takes  too 
much  time.  One  should  take  care  to  have  several  sizes  of  silk,  espe- 
cially the  o  and  00;  for  these  are  the  sizes  required  in  intestinal 
work.     Silk  and  silkworm-gut  may  be  sterilized  as  needed. 

Catheters  and  bougies  should  be  kept  in  a  metallic  box.  Rubber 
and  metal  catheters  are  always  readily  sterilized  by  boiling.  Rubber 
catheters  deteriorate  rapidly  unless  properly  cared  for.  They 
may  break  unexpectedly,  the  result  of  an  unnoticed  change  in 
quaUty,  and  a  piece  be  left  in  the  bladder. 


CARE    OF   INSTRUMENTS  5 

Drainage  Tubes. — These  should  be  preserved  in  a  box  or  bottle 
which  may  be  boiled  thoroughly  before  opening. 

Plaster  should  be  kept  in  a  tin  box  with  tight  cover  and  may  be 
loose  or  already  rolled.  A  supply  of  roller  bandages  is,  of  course, 
always  kept  on  hand,  from  which  the  plaster  bandages  may  be 
made. 

Instruments. — -Any  list  which  might  be  enumerated  must,  of  course, 
be  subject  to  the  widest  variation.  But  the  feeling  of  greatest 
confidence  goes  with  the  consciousness  of  having  the  necessary  things 
with  which  to  act.  On  the  whole,  the  doctor  should  pride  himself 
upon  the  completeness  of  his  outfit,  rather  than  upon  his  ability  to 
improvise.  One  should  have  as  the  minimum:  scalpels,  two  sizes 
of  amputating  knives,  scissors,  grooved  director,  dissecting  forceps, 
artery  forceps — the  more  the  better — two  retractors,  a  saw,  a  bone 
chisel,  needle  holder  and  needles,  tracheotomy  tubes,  and  an  Esmarch 
tube.  The  instruments  most  frequently  used  may  be  put  together 
in  a  small  metal  case,  while  the  others  may  be  kept  in  larger  cases, 
or  wrapped,  or  rolled  up  in  a  bundle. 

Cleaning  instruments  and  preserving  them  from  rust  is  a  matter 
of  no  small  importance.  After  each  operation  they  should  be  taken 
apart,  scrubbed  with  soap  and  warm  water,  wiped  with  gauze 
saturated  with  alcohol,  and  dried  thoroughly.  If  the  cleansing  has 
been  delayed,  it  may  be  necessary  to  immerse  them  for  a  short 
time  in  a  solution  of  potash,  and  finally  cleanse  in  the  manner  de- 
scribed. If  any  stains  still  persist  they  should  be  polished  with 
chamois  skin. 

Formaldehyde,  certain  acids,  and  iodine  in  too  close  proximity, 
tarnish  and  spoil  instruments  in  spite  of  care. 

A  dish  or  two  of  calcium  chloride  in  the  instrument  case  will 
absorb  moisture  and  tend  to  prevent  rusting.  Too  often  the  practi- 
tioner neglects  his  instruments  because,  perhaps,  not  often  used; 
and,  in  the  emergency,  he  finds  himself  with  knives  rusty  and  with- 
out an  edge,  scissors  that  will  not  cut,  and  forceps  that  have  no 
grip.  He  will  certainly  gain  time  by  spending  a  little  time  in  carry- 
ing out  these  small  details  in  the  care  of  his  tools. 


CHAPTER  II 

EMERGENCY    ANTISEPSIS.    OPERATION    IN    A  PRIVATE 

HOUSE 

The  preparation  for  an  urgent  intervention  outside  of  an  operating 
room  resolves  itself  into  a  question  of  asepsis  or  antisepsis,  and 
around  this  point  gathers  a  multitude  of  details.  But  it  is  necessary 
only  to  proceed  systematically  and  intelligently  to  achieve  excellent 
results. 

The  time  was  when  the  idea  prevailed  that  an  aseptic  operation 
was  scarcely  possible  outside  a  hospital.  This  was  a  harmful  notion 
which  restrained  many  a  practitioner  from  an  effort  that  might  have 
saved  his  patient's  life.  Every  day  it  is  demonstrated  that  aseptic 
work  is  not  peculiar  to  formal  operating  rooms. 

Bonney,  of  Philadelphia,  writes  that  he  has  done  many  major 
operations  in  the  homes  of  the  poor  in  the  midst  of  the  most  unsurgical 
surroundings;  nevertheless,  the  results  have  been  excellent.  Most 
of  these  operations  were  for  urgent  abdominal,  pelvic,  or  genito- 
urinary disease,  and  though  such  work  is  often  time-consuming 
and  laborious,  yet  it  shows  what  can  be  done  in  the  case  of  necessity. 

Garrison  of  Birmingham  (Ala.)  concludes  a  useful  paper  touching 
this  subject  with  the  statement  that  of  a  thousand  cases  operated  in 
the  last  ten  years  in  the  patients'  homes  the  mortality  rate  was  zero, 
except  that  in  a  series  of  abdominal  gunshot  cases  three  died.  (Amer. 
Jour.  Surg.,  Aug.,  1914.) 

Van  der  Walker  (Month  Cyclopedia  of  Pract.  Med.,  Aug.,  1906) 
says  that  for  thirty  years  he  has  operated  in  farm  houses  through- 
out central  New  York  with  as  good  results  as  those  obtained  in  the 
hospital  with  which  he  was  connected  for  many  years.  He  goes 
further  and  concludes  that,  for  many  reasons,  it  is  desirable  that 
there  should  be  a  return  to  more  home  operating,  and  that  the 
hospital  ought  to  go  back  to  its  original  purpose,  the  care  of  the 

6 


PREPARATION   OF   MATERIALS  7 

homeless  and  sick  poor,  and  not  invade  the  home  with  the  arrogant 
assurance  that  only  within  its  walls  can  the  surgical  case  be  cared 
for. 

But  this  is  aside  from  the  main  point:  the  practitioner  may  feel 
assured  that  with  decision,  knowledge,  and  system,  even  under  ap- 
parently unfavorable  circumstances,  he  can  nearly  always  realize  an 
effective  asepsis. 

AsLejars  says,  everywhere  one  finds  water,  fire,  and  linen;  add  salt 
and  usually  carbonate  of  soda:  with  these  one  may  accomplish  a 
sufficient  sterilization  of  the  instruments,  the  hands,  the  field  of  opera- 
tion and  the  dressing.  But  it  requires  a  will  to  do  all  the  work,  to 
proceed  with  method  and,  above  all,  quickly,  through  the  minutiae 
of  preparation.  One  should  have  a  plan  in  mind  and  Lejars  offers 
a  model  which,  of  course,  can  be  modified  to  suit  the  circumstances 
and  the  operation.  Suppose  a  major  emergency,  with  every  detail 
of  the  preparation  to  be  supervised: 

First  Step. — Have  a  fire  started.  Have  the  available  receptacles 
assembled.  Review  the  stock  of  linens  if  you  do  not  have  gauze 
or  muslin.  Freshly  laundered  handkerchiefs  and  napkins  (without 
fringe)  furnish  material  for  excellent  compresses  and  coverings  for 
the  field  of  operation.  Secure  one  or  two  large  kettles — a  copper 
wash-boiler— for  boiling  the  water  for  the  operation.  Secure  three 
smaller  receptacles  such  as  enameled  stewing-pans :  one,  for  boiling 
the  instrument  and  sutures;  another,  for  the  brushes,  irrigator, 
nozzles  and  tube,  etc. ;  the  third,  for  the  compresses  and  tampons.  If 
possible,  boil  also  the  dishes  or  basins  selected  to  hold  the  instruments 
and  the  solutions  needed  during  the  operation.  It  is  best  to  have  a 
dish  or  bowl  for  the  instruments,  one  for  the  tampons  and  compresses, 
one  for  the  sutures,  and  two  hand  basins  for  sterile  water  and 
bichloride  solution.  The  boiling  must  be  prolonged  at  least  a  half 
hour  to  be  sure  of  sterilization.  It  is  a  good  plan  to  add  a  teaspoon- 
ful  of  salt  to  the  quart  of  water  containing  the  compresses  which  are 
to  be  tied  up  in  a  towel  to  facilitate  their  removal;  and  to  add  a  tea- 
spoonful  of  washing  soda  to  the  water  in  which  the  instruments  are 
to  boil,  since  it  more  readily  removes  grease  or  blood,  makes  the 
temperature  slightly  higher,  and  prevents  rusting.  The  knives 
should  be  wrapped  in  soft  gauze  to  prevent  dulling;  still  better 


8  EMERGENCY   ANTISEPSIS 

edged  instruments  should  not  be  boiled  at  all  but  merely  immersed 
in  alcohol  for  some  time  previous  to  the  operation.  The  instruments 
ought  not  to  be  put  in  until  the  water  is  boiling,  as  otherwise  they 
are  Hkely  to  be  tarnished.  If  it  is  necessary  to  boil  the  instruments 
and  suture  material  together,  the  soda  should  not  be  added,  since  it 
rapidly  ruins  both  silk  and  silkworm-gut.  Even  better  than  boil- 
ing water  for  sterilizing  instruments  is  hot  oil — 'olive  oil,  for  example 
— since  its  boiling-point  is  a  higher  than  that  of  water.  The  vessel 
containing  the  oil  can  be  set  in  another  of  cold  water  and  instruments 
may  soon  be  taken  from  the  oil  ready  for  use.  This  oil  may  be  used 
again  many  times.  Five  minutes  of  actual  boiling  is  sufficient  to 
sterilize  instruments.  When  once  the  sterilization  is  under  way 
proceed  to  the  operating  room. 

Second  Step.  Prepare  the  Operating  Room  and  Table. — -If  there  is 
any  choice,  select  the  best  lighted  and  largest  room.  If  it  is  at 
night,  arrange  for  the  illumination.  Do  not  displace  the  furniture 
except  to  make  room  for  the  operating  table,  two  small  tables,  and 
room  to  "turn  about."  An  extensive  "clearing  for  action"  does 
more  harm  than  good,  for  by  jerking  down  the  curtains,  rolling  the 
furniture  around  and  sweeping,  one  stirs  up  the  dust,  accumulating 
perhaps  for  months. 

It  is  preferable  simply  to  sprinkle  the  floor  or  wipe  with  a  wet 
cloth.  To  be  sure,  if  one  has  several  hours  in  which  to  prepare,  then 
the  room  may  be  emptied,  the  floor  covered  with  moist  sheets  and 
the  walls  sprayed,  as  Quenu  suggests,  with  peroxide,  the  tables  placed 
and  the  room  closed  until  the  time  of  operating. 

It  is  never  a  good  idea  to  use  the  patient's  bed  for  an  operating 
table,  although  the  first  preparation,  as  the  shaving,  may  be  begun 
there.  The  dining  table  can  usually  be  pressed  into  service,  covered 
with  a  blanket  and  that  with  an  oilcloth.  A  table  may  be  im- 
provised from  two  wooden  trestles  with  planks  laid  across  and 
covered  like  the  table.  Of  the  two  small  tables  required,  the  one  on 
the  assistant's  side  will  hold  the  compresses,  sutures,  etc. ;  the  other 
on  the  operator's  side  will  hold  the  instruments. 

Now  give  the  patient  the  preliminary  preparation.  Shave  the 
parts  always  when  possible,  first  lathering  with  soap  and  hot  water. 
The  razor  is  almost  indispensable  as  an  agent  of  disinfection,  for  it 


PREPARATION    OF   THE   HANDS  9 

removes  the  hair  and  the  superficial  layer  of  the  epidermis.  It  is  a 
common  fault  to  be  too  sparing  with  its  use.  In  operations  on  the 
skull,  the  whole  scalp  should  be  shaved.  The  shaving  may  be  done 
after  the  patient  is  anesthetized;  but,  as  a  rule,  everything  possible 
should  be  done  to  curtail  the  anesthesia.  If  the  operation  is  likely  to 
be  prolonged,  wrap  the  lower  limbs  in  blankets,  and  speak  for  hot 
irons  or  water  bottles. 

Third  Step. — Everything  having  boiled  sufficiently,  carry  the 
vessels  into  the  operating  room  and  empty  the  contents  of  each  into 
its  special  receptacle,  which  of  course  must  first  be  sterilized. 

If  these  bowls  have  not  been  boiled,  as  previously  directed,  now 
is  the  time  to  sterilize  them  by  singeing  with  burning  alcohol.  Into 
each  pour  two  or  three  spoonfuls  of  alcohol  and  set  it  on  fire,  in  the 
meantime  tilting  the  dish  in  various  directions  so  that  the  flame  is 
brought  in  contact  with  the  whole  inner  surface.  When  this  is 
done,  lift  the  compresses  and  instruments  out  of  their  boilers,  place 
them  in  these  sterile  dishes  and  cover  them  with  an  antiseptic 
solution.  This  protects  them  from  possible  contamination  until 
the  operation  begins.  Do  not  open  the  bag  of  compresses  till 
needed.  Remember  to  use  only  a  sterile  dipper,  if  necessary  to 
dip  out  the  sterile  water  in  preparing  the  various  solutions. 

Fourth  Step. — Direct  the  assistant  to  begin  the  anesthesia,  and 
now  prepare  your  hands.  As  Lejars  remarks,  this  is  a  "science  and 
art,"  the  first  duty  of  the  surgeon.  They  are  not  to  be  prepared  by  a 
desultory  rinsing  in  soapy  water,  or  parboiling  with  a  hot  antiseptic 
solution,  but  by  a  patient  and  systematic  scrubbing.  Get  your 
sleeves  rolled  up  and  pinned.  Have  before  you  two  wash  basins, 
one  with  hot  and  the  other  with  cold  sterile  water.  Pare  the  nails. 
Begin  with  soap  and  hot  water.  Lather  the  arms  up  to  the  elbow, 
and  rub  the  soap  in  until  the  skin  seems  saturated  and  soft.  Then 
begin  with  the  brush;  scrub  the  palms,  the  dorsum  of  the  hand,  be- 
tween the  fingers,  all  about  the  nails.  One  need  not  rub  the  skin 
off,  to  be  sure,  but  the  disinfection  must  be  complete.  The  water 
should  be  changed  several  times,  if  possible;  next  rinse  in  cold  sterile 
water  and  then  rub  vigorously  with  alcohol  to  remove  all  the  oils 
in  the  skin;  finally  soak  in  bichloride  solution.  The  cleansing  will 
probably  occupy  ten  minutes.     The  antiseptics  used  vary  with  the 


lO  EMERGENCY   ANTISEPSIS 

operator,  but,  after  all,  it  is  the  soap  and  hot  water  which  is  most 
important.  At  the  Indianapolis  City  Hospital  the  routine  is  scrub- 
bing with  soap  and  water;  rinsing  in  lysol;  rinsing  in  sterile  water; 
and  finally  scrubbing  thoroughly  with  gauze  saturated  with  alcohol. 
In  an  emergency  one  might  feel  safe  in  using  the  alcohol  alone. 

Alcohol  as  a  disinfecting  agent  has  the  disadvantage  that  it  fixes 
the  blood  of  the  operation  on  the  skin  but  this  may  be  removed  by 
peroxide  or  a  warm  solution  of  sodium  carbonate. 

Rubber  gloves  are  almost  universally  employed  in  hospital  clinics. 

Gloves  are  trying  to  the  temper  where  the  surgeon  must  manage 
them  himself.  One  plan  is  to  fill  them  with  the  solution  used  in 
the  operation  and  which  is  squeezed  out  after  the  hand  is  in  place. 

Burmeister  says  that  just  before  putting  on  the  gloves,  he  rubs 
two  tablespoonfuls  of  bolus  alba  with  a  little  water  over  his  hands 
so  that  they  are  covered  with  the  thick  paste,  enabling  the  glove  to 
be  pulled  on  and  off  easily,  protecting  it  against  tearing  and  be- 
sides the  paste  has  a  soothing  action  on  the  skin.  (Zent.  blatt.  f. 
Chirurg,  Leipsic,  Feb.,  191 3.)  They  are  probably  an  extra  guar- 
antee against  infection,  but  are  by  no  means  indispensable.  As 
good  plan  as  any,  perhaps,  is  to  use  them  always  where  infective 
processes  are  likely  to  be  met  with;  thus  the  operator  is  protected; 
and,  besides,  his  hands  are  kept  free  from  septic  agents  which  might 
be  difficult  to  remove. 

Fifth  Step. — In  the  meantime  the  anesthesia  has  progressed. 
When  it  is  well  under  way,  prepare  the  field  of  operation^  which  we 
assume  has  been  previously  shaved,  by  scrubbing  with  soap  and 
water,  followed  by  alcohol  or  ether  and  bichloride  solution.  Har- 
rington's solution  is  much  employed  and  consists  of 

Mercuric  chloride,  .8  g. 

Acid  hydrochloric,  60  c.c. 

Water,  300  c.c. 

Alcohol,  640  c.c. 

Iodine  is  quite  commonly  used  and  for  emergency  work  is  prefer- 
able. In  this  case  the  skin  is  shaved  dry,  scrubbed  with  ether  or 
alcohol  and  the  plain  Tr.  of  iodine  applied  and  allowed  to  dry. 
Another  application  is  made  and  when  it  dries  the  sterilization  is 
complete. 


DISINFECTION   OF   THE   SKIN  H 

In  the  case  of  the  abdomen,  particularly,  the  iodine  should  be 
finally  removed  by  use  of  alcohol.  But,  whatever  method  may  be 
employed,  the  disinfection  of  the  skin  must  be,  in  every  respect,  as 
thorough  and  vigorous  as  that  of  the  hands,  and  must  extend  well  beyond 
the  proposed  line  of  incision  in  all  directions,  for  one  can  never  tell 
where  the  incision  may  finally  end.  A  large  area  is  almost  as 
rapidly  prepared  as  a  small  one.  For  example,  in  laparotomies 
the  whole  abdomen  should  be  included,  as  well  as  the  lower  half  of 
the  thorax.  In  hernia  operations,  the  abdomen  as  far  as  the  um- 
bilicus, the  groin  and  the  genitals.  In  amputations  of  the  leg,  the 
thigh  should  be  included  in  the  cleansing;  and  in  amputations  of 
the  thigh,  the  whole  region  of  the  pelvis. 

Again  wash  your  hands.  An  untrained  assistant  changing  the 
bowls  may  spoil  the  sterilization  by  getting  his  fingers  or  thumbs 
inside.  Direct  him  how  to  lift  and  carry  a  bowl  with  his  palms 
against  the  outside. 

Having  completed  the  final  cleansing  of  the  hands,  cover  the 
field  of  operation  on  the  four  sides  with  four  sterile  towxls  or  large 
compresses  and  fasten  them  with  sterile  safety  pins  or  artery  forceps. 

Time  gained  by  relaxing  in  the  least  any  of  these  precautions  of 
asepsis  and  antisepsis,  is  irretrievably  lost;  it  is  the  operation,  now 
begun,  which  must  progress  rapidly. 


CHAPTER  III 
ANESTHESIA 

Anesthesia  is  necessary  in  most  emergency  operations,  not  only 
to  obviate  pain,  but  because  it  is  often  essential  to  a  good  operation. 
Unfortunately,  on  the  other  hand,  it  adds  to  the  doctor's  task  and 
presents  some  special  difficulties. 

In  certain  grave  conditions,  as  intestinal  occlusion,  strangulated 
hernia,  or  abdominal  traumatism,  it  may  be  the  immediate  cause  of 
death,  however  carefully  administered. 

Not  only  in  emergency  work,  but  in  any  case,  general  anesthesia 
should  be  cautiously  induced  and  narrowly  watched;  and  for  this 
reason  it  is  especially  embarrassing  to  the  doctor  compelled  to 
entrust  it  to  the  untrained  in  cases  of  urgency. 

Chloroform  has  the  advantage  that  it  requires  no  special  apparatus 
for  its  administration;  and  the  smaller  bulk  is  an  item  of  importance, 
especially  in  military  practice;  moreover,  it  is  much  more  pleasant 
to  the  patient.  Unfortunately,  it  is  many  times  more  dangerous 
than  ether,  even  in  the  hands  of  the  skilled. 

In  lieu  of  a  special  inhaler,  such  as  Esmarch's,  fold  a  handker- 
chief, napkin,  or  compress  several  times  to  form  a  square.  Begin 
by  pouring  on  several  drops  and  gently  approaching  it  to  the  mouth 
and  nose  of  the  patient.  The  inhaler  should  be  managed  with  the 
left  hand,  leaving  the  right  hand  free  to  raise  the  eyelid,  or  feel  the 
pulse,  or  handle  the  container.  Do  not  hold  it  too  close  to  begin 
with,  but  give  the  patient  plenty  of  air;  in  other  words,  give  the 
chloroform  well  diluted.  Give  the  patient  time  to  get  accustomed 
to  the  odor.  Advise  him  to  breathe  through  the  mouth  and  dis- 
tract his  attention  as  much  as  possible;  get  his  confidence,  flatter 
him,  and,  in  the  meantime,  study  him  and  test  him.  The  few  min- 
utes spent  in  this  way  will  soon  be  regained. 

Pour  on  five  or  six  drops  of  chloroform  at  a  time;  and,  as  the 
respiration  becomes  deeper,  hold  the  inhaler  closer,  giving  the 
chloroform  less  diluted  with  air.     Replenish  the  supply  every  half 

12 


r 


CHLOROFORM  ANESTHESIA  I3 

minute,  sprinkling  it  on  the  under  side  of  the  compress  and  quickly 
inverting  in  over  the  face. 

As  the  stage  of  excitement  comes  on,  push  it  more.  When  the 
anesthesia  is  complete,  reduce  the  dosage  but  increase  the  frequency 
of  renewal. 

The  drop  method  is  ideal  after  the  anesthesia  has  been  attained. 
Small  doses  frequently  applied  mean  the  smallest  total  amount, 
which  must  be  the  anesthetist's  constant  aim  (Fig.  i). 

The  goo'd  anesthetist  is  not  the  one  who  can  use  the  largest  amount 
of  chloroform  without  death,  but  the  one  who  can  hold  the  patient 
merely  unconscious  and  relaxed  with  the  smallest  amount  possible. 


Fig.  I. — Chloroform  container. 

If  the  patient  coughs  or  shows  signs  of  nausea,  increase  the  dosage 
at  once.  Do  not  begin  the  preparation  of  the  field  or  any  part  of 
the  operation  until  the  anesthesia  is  complete. 

Keep  the  pulse,  the  pupil,  the  face,  and  the  thorax  under  con- 
stant surveillance,  for  in  this  way  alone  may  one  determine  the 
prognosis,  good  or  bad,  of  the  anesthesia. 

The  anesthesia  is  usually  described  as  occurring  in  three  stages: 
the  first,  stage  of  excitement;  the  second,  loss  of  consciousness;  the 
third,  loss  of  reflexes  or  stage  of  surgical  anesthesia.  There  is  a 
fourth,  stage  of  paralysis  of  the  •automatic  centers,  but  this  is  a 
stage  which  the  good  anesthetist  will  never  reach. 

The  excitement  of  the  initial  stage,  in  which  the  patient  struggles 
or  talks  at  random,  is  followed  by  loss  of  consciousness,  but  the  re- 
flexes are  active,  the  pulse  is  full  and  bounding,  the  pupils  respond 
to  light,  the  eyelid  resents  the  corneal  touch,  the  skin  is  sensitive, 
the  face  is  flushed,  and  the  breathing  deep  and  regular. 


14  ANESTHESIA 

Beware  at  this  time  of  sudden  blanching  of  the  face,  of  dilated 
pupils,  of  weakened  pulse,  or  disturbed  breathing.  If  these  symp- 
toms arise,  withdraw  the  anesthetic  and  prepare  for  artificial  respira- 
tion. The  patient  is  not  ready  for  the  operation  and  yet  he  may  die 
in  this  stage. 

Pallor  and  dilated  pupils  often  precede  vomiting,  but  when  the 
pulse  and  respiration  are  good,  the  nausea  is  to  be  quieted  by  more 
chloroform. 

When  the  reflexes  are  finally  aboHshed,  the  pulse  should  be  full, 
though  perhaps  a  little  slowed,  the  respiration  quiet  and  regular, 
the  pupils  sHghtly  contracted,  and  the  face  moderately  pale.  Any 
marked  deviation  from  this  standard  during  the  operation  is  a 
matter  for  concern. 

Weak  heart  action,  uncertain  respiration,  dilated  pupils,  deep 
pallor  or  cyanosis,  mean  approaching  paralysis  of  the  automatic 
centers  governing  the  circulation  and  respiration,  and  the  anesthetic 
must  be  withdrawn  until  the  symptoms  improve  under  measures 
employed  to  stimulate. 

In  the  case  of  the  average  adult,  one  andone-half  to  two  ounces 
should  be  sufl&cient  for  the  first  hour  and  much  less  subsequently. 
Children  and  the  debilitated  require  less. 

Ether  has  the  disadvantages  in  emergency  work  that  it  is  danger- 
ous to  use  near  a  Hght  or  fire,  and  that  its  administration  is  a  little 
more  complicated;  but,  beyond  that,  its  anesthesia  is  never  at- 
tended by  sudden  death  in  the  early  stages,  as  is  that  of  chloroform. 
It  is  followed  by  less  shock  after  abdominal  operations  or  other  pro- 
longed intervention.  Bronchial  affections  are  its  chief  counter- 
indications. 

Ether  may  be  administered  by  the  drop  method  using  the  same 
mask  as  for  chloroform  (Fig.  2)  and  the  same  general  method  (Fig. 
3).  Or  an  inhaler  may  be  fashioned  out  of  a  newspaper  rolled  into 
a  cone,  cotton  or  gauze  fastened  in  its  apex,  on  which  the  ether 
is  poured.  Begin  with  a  drachm;  let  the  patient  get  accustomed 
gradually  to  the  ether,  diluting  it  well  with  air  by  holding  the  inhaler 
an  inch  or  so  from  the  face  and  gradually  approaching.  In  that  way, 
the  feeling  of  suffocation  is  avoided.  As  the  patient  approaches 
unconsciousness,   hold   the   mask   closely   so   as  to  shut  out  the 


ETHER   ANESTHESIA 


15 


air,  and  the  stage  of  anesthesia  will  be  quickly  reached    without 
excitement. 


Fig.  2. — Administration  of  ether  by  the  drop  method.     Mask,  with  and  without  gauze 
covering.    Appliance  for  regulating  flow,  unattached,  to  right  of  ether  can. 

If  one  proceeds  timidly  at  this  stage,  the  anesthesia  will  be  hard 
to  obtain  and  much  more  ether  will  be  required.     Once  the  reflexes 


Fig.  3. — Administration  of  ether.     Appliance  regulating  flow  attached  to  can. 

are  abolished,  use  small  quantities,  frequently  applied.     The  acci- 
dent most  to  be  feared  is  respiratory  paralysis. 


l6  ANESTHESIA 

The  signs  indicating  the  favorable  progress  of  ether  anesthesia 
during  the  operation  are:  pulse  full  and  regular;  respiration  deep  and 
slightly  snoring;  face  flushed;  and  pupils  slightly  dilated.  Cyanosis 
is  the  signal  for  more  oxygen.  Any  disturbance  of  the  respiration 
demands  immediate  attention.  Occasionally  patients  will  be 
found  who  do  not  take  ether  well,  but  who  will  take  chloroform  with- 
out the  least  untoward  effect. 

TREATMENT  OF  THE  ACCIDENTS  OF  ANESTHESIA 

Certain  measures  are  recommended  as  forestalling  the  dangers 
of  anesthesia;  though  they  are,  as  a  rule,  more  appropriate  to  the 
general  surgery  of  hospitals. 

A  preliminary  gastric  lavage  will  save  embarrassment  in  certain 
cases.  In  fact,  this  should  be  an  invariable  rule,  when  compelled 
to  operate  on  patients  who  have  eaten  only  a  short  time  previously. 
A  preliminary  subcutaneous  injection  of  normal  salt  solution  will 
sustain  the  patient  in  the  cases  of  anemia  and  grave  septic  infection. 

Many  surgeons  precede  a  chloroform  anesthesia  by  hypodermic 
injection  of  morphine  or  strychnine,  or  of  morphine  and  atropine, 
thirty  minutes  before  the  anesthesia.  This  is  desirable  especially  in 
operations  on  regions  in  which  the  reflexes  are  rnore  active,  for  there 
is  scarcely  a  doubt  that  some  of  the  circulatory  disturbances  under 
chloroform  are  reflected  from  the  field  of  operation.  This  is  true  of 
the  testicle,  the  spermatic  cord,  the  anus,  and  the  peritoneum.  None 
of  these  methods  lessens  the  anesthetist's  responsibility  and  duty  to 
watch  every  point. 

If  the  circulation  grows  weak,  the  pulse  small,  rapid,  compres- 
sible, due  to  the  effect  of  the  anesthetic  agent  and  not  to  shock  or 
hemorrhage,  withdraw  the  agent  and  lower  the  head,  draw  out  the 
tongue  and  begin  artificial  respiration,  and  the  danger  is  usually 
soon  passed. 

Hypodermic  injection  of  stimulants,  such  as  strychnia  or  camphor- 
ated oil  often  do  good  under  these  circumstances;  but  when  the 
circulation  is  paralyzed  and  syncope  has  supervened,  their  use  is 
illusory.  Do  not  waste  time  preparing  them,  though  an  assistant 
may  do  so;  but  proceed  to  make  rhythmic  traction  on  the  tongue, 


ARTIFICIAL   RESPIRATION 


17 


and  artificial  respiration,  both  being  carried  out  methodically.  If 
an  assistant  is  at  hand,  carry  out  the  two  measures  simultaneously; 
otherwise,  try  the  tongue  traction  first,  or  at  least  get  it  pulled  out 
well.  Traction  of  the  tongue  to  do  good,  must  be  rhythmic.  The 
tongue  must  be  caught  up  carefully  with  forceps  and  no  force  must 
be  used.  Often  the  tongue  is  seriously  injured  by  the  feverish  pulls 
of  the  agitated  operator,  who  has  quite  forgotten  that  the  maneuver 
is  effectual  only  when   rhythmic. 

The  artificial  respiration  must  likewise  be  rhythmic. 

Grasp  the  patient's  elbows  and  draw  them  gently  and  steadily 
upward  until  they  meet  above  the  head.  The  pectoral  muscles  are 
put  upon  the  stretch  and  the  chest  expanded  and  inspiration  pro- 
duced.    At  the  same  time  the  tongue  is  drawn  outward  (Fig.  4). 


Fig.  4. — Stage  of  inspiration.     Tongue  should  be  drawn  out  with  this  movement.     {Stewart.) 


The  arms  are  next  brought  with  a  steady  movement  to  the  chest 
wall  and  the  diaphragm  compressed.  (Stage  of  expiration.)  At 
the  same  time,  the  tongue  is  permitted  to  retract  (Fig.  5). 

These  movements  are  to  be  repeated  at  the  rate  of  about  twenty 
per  minute  and  should  be  persisted  in  without  intermission  for  at 
least  a  half  hour  before  giving  up  hope  of  resuscitation. 

Direct  compression  of  the  heart  is  a  procedure  of  real  value  and  it 
may  often  be  readily  managed  through  the  abdominal  walls.  In  the 
case  of  abdominal  operations,  the  hand  may  be  passed  up  to  the 
diaphragm  and  the  heart  seized  and  kneaded  in  that  manner. 

The  vomiting  after  anesthesia  is  often  troublesome  and  is  usually 


i8 


ANESTHESIA 


in  direct  ratio  to  the  amount  of  the  agent  used.  Every  effort  should 
be  made  to  hasten  its  elimination  from  the  blood  by  keeping  the  skin 
warm  and  active,  and  helping  the  kidneys  with  saline  enemata. 
These  enemata  also  diminish  thirst.  Warm  soda  water  drunk  freely 
helps  to  wash  out  the  stomach  and  thus  hastens  relief  of  active  vomit- 
ing. Five  to  fifteen  drops  of  aromatic  spirits  of  ammonia  hypo- 
dermically,  or,  well  diluted,  by  mouth,  often  does  good.  Both 
these  agents  probably  do  good  by  relieving  acidosis  which  is  a  large 
factor  in  producing  post-anesthetic  troubles. 


Fig.  S. — Stage  of  expiration.     Tongue  permitted  to  drop  back  in  mouth.     (Stewart.) 

If  there  are  evidences  of  beginning  acute  gastric  dilatation,  gastric 
lavage  must  be  used  early. 

Other  forms  of  general  anesthesia  will  not  often  be  of  service  in 
emergency  practice  for  obvious  reasons,  however  valuable  they  may 
otherwise  be.  It  is  hardly  necessary,  therefore,  to  consider  nitrous 
oxide  or  ethyl  chloride  and  their  congeners ;  or  general  anesthesia  by 
way  of  the  rectum,  which  promises  to  be  of  value  in  operations  on 
the  face,  mouth,  neck,  and  thorax;  or  hedonal  and  ether  intraven- 
ously which  has  been  the  subject  of  good  reports. 


LOCAL  ANESTHESIA 

The  doctor,  isolated  and  without  assistants,  will  many  times  find 
aid  and  comfort  in  local  anesthesia  by  hypodermic  injection;  but 
to  be  efficient,  it  must  be  properly  induced.     A  definite  technic  must 


LOCAL  ANESTHESIA 


19 


be  followed.  Either  cocaine  or  stovaine  may  be  used,  the  latter 
safer,  the  former  slightly  more  active,  the  two  used  alike.  Having 
determined  the  line  of  incision,  pinch  up  a  fold  of  skin  (Fig.  6), 
introduce  the  needle  at  one  end  of  the  line  and  push  it  into  the  skin, 
but  not  through  the  skin.     The  injection  is  intradermal  (Fig.  7). 


Fig.  6. — Local  anesthesia;  method  of  introducing  needle.     {Veau.) 

As  the  needle  is  steadily  advanced,  the  syringe  is  emptied  slowly, 
and  the  line  of  injection  is  indicated  by  the  formation  of  a  wheal. 
When  the  needle  has  entered  its  length,  it  is  reintroduced  in  the  same 
line  and  in  advance  of  the  previous  puncture,  but  within  the  area 
already  anesthetized.  In  this  way,  only  the  first  puncture  is  felt. 
When  the  line  of  incision  has  been  infiltrated  in  this  manner  through- 


I 


'i'^^'^wmm^iti 


Fig.  7. — Local   anesthesia;   the   needle   does   not   penetrate   the    whole 
thickness  of  skin;  " intra-dermic "  injection.     (Veau.) 

out  its  entire  length,  it  will  be  completely  insensitive  after  a  wait  of 
one  to  two  minutes.  The  width  of  the  zone  of  anesthesia  will  de- 
pend upon  the  rate  of  movement  of  the  needle  through  the  skin 
(Figs.  8,  9).  It  need  hardly  be  said  that  the  needle  and  solution  must 
always  be  sterile.     It  is  better  to  pour  the  solution  out  into  a  sterile 


20 


ANESTHESIA 


dish  or  glass,  rather  than  to  aspirate  it  from  the  bottle.  The  air 
must  be  forced  out  before  the  needle  is  introduced;  care  must  be 
taken  not  to  throw  the  injection  into  a  vein. 

When  an  area,  rather  than  a  line,  is  to  be  infiltrated,  as  in  case 
some  dissection  is  anticipated,  Schleich's  method  is  better,  in  which 
the  needle  is  plunged  directly  into  the  tissues  and  a  sufficient  quan- 


FiG.  8. — Local  anesthesia;  the 
zone  of  infiltration  is  narrow 
when  the  needle  is  pushed  for- 
ward and  emptied  rapidly. 
(Veau.) 


A/l 


Fig.  0. — Local  anesthesia;  the 
zone  is  broad  when  the  needle  is 
introduced  slowly.      {Veau.) 


tity  of  the  solution  discharged  to  raise  a  wheal.     The  needle  is  then 
reintroduced  alongside  the  wheal  for  another  injection.     The  anes- 
thesia may  be  renewed  from  time  to  time  during  the  operation. 
Schleich's  formula  is  as  follows: 


NO,    I,    STRONG. 

Cocain.  hydrochlor., 

gr.  iii. 

Morphin.  hydrochlor., 

gr-  5^. 

Sodii  chloridi., 

gr.  iii. 

Aq.  destillat., 

5  iii,  5  iiss 

NO.    2,    NORMAL. 

Cocain.  hydrochlor., 

gr.  iss. 

Morphin.  hydrochlor.. 

gr.  %. 

Sodii  chloridi., 

gr.  iii. 

Aq.  destillat., 

§  iiiss. 

LOCAL   ANESTHESIA 


21 


IN 

10.    3,    WEAK. 

Cocain.  hydrochlor., 

gr.  'A. 

Morphin.  hydrochlor., 

gr.  IK'. 

Sodii  chloridi., 

gr.  iii. 

Aq.  destillat., 

5  iiiss 

Two  or  three  drops  of  a  50  per  cent,  solution  of  carbolic  acid  may 
be  added  to  preserve.  The  solution  must  be  kept  cool.  Twenty- 
five  syringefuls  of  Number  i,  fifty  syringefuls  of  Number  2,  and 
500  of  Number  3,  may  be  used  without  danger.  Novocaine  in  M 
per  cent,  solutions  is,  we  think,  even  better  than  Schleich's   solu- 


FlG.  10.— The  finger  may  be  anes- 
thetized by  a  circular  injection  at  its 
base.     {Veau.) 


Fig.  II. — Complete  anesthesia  of  fin- 
ger induced  by  deep  injections  on  each 
side.  The  upper  and  lower  needle, 
represent  the  primary  circular  fnjections. 
(Veau.) 


How- 


tion,  though  in  equal  quantities  slightly  more   dangerous, 
ever,  smaller  quantities  are  required. 

The  patient  should  not  be  permitted  to  sit  up  during  the  anes- 
thesia if  cocaine  is  used,  for  it  exposes  him  to  the  risk  of  heart 
failure.     It  is  safer  to  keep  him  recumbent  for  a  half  hour  or  so  after 

the  operation. 

If  a  finger  or  toe  is  to  be  amputated,  first  make  an  anesthetic 
ring  involving  the  skin  only  (Fig.  10),  and  follow  this  with  two  deep 
lateral  injections  to  obtund  the  main  nerve  trunks  (Fig.  11). 


22  ANESTHESIA 

SPINAL  ANESTHESIA 

Spinal  anesthesia  wdth  stovaine  can  only  very  rarely  be  of  use  to 
the  general  practitioner  in  emergency  work,  although  it  is  of  value 
under  certain  circumstances.  It  is  of  special  use  in  operations  in- 
vohnng  the  anal  and  perineal  regions.  By  this  method  the  heart 
and  lungs  are  not  dangerously  affected.  It  is  a  solace  to  those  pa- 
tients whose  dread  of  a  general  anesthesia  is  greater  than  their  dread 
of  death,  and  who  will  refuse  operations  of  absolute  necessity  rather 
than  take  ether  or  chloroform.  The  most  definite  contra-indica- 
tion  is  uncertainty  of  asepsis,  since  the  chief  danger  of  the  procedure 
is  meningitis.  It  should  not  be  used  in  the  young,  in  advanced 
arterio-sclerosis,  in  cases  of  septicemia,  or  central  ner\'ous  disease. 
The  average  duration  of  the  analgesia  thus  produced  is  one  hour. 
The  effects  are  fairly  uniform;  the  chief  after-effects  are  headache 
and  nausea.  One  of  the  author's  patients,  operated  for  hernia 
under  spinal  anesthesia  complained  for  several  months  of  loss  of 
sensation  in  the  penis  and  rectum,  though  not  materially  interfering 
with  the  functions  of  either.  The  preparation  employed  by  the 
author  is  that  of  Chaput:  stovaine.  lo  gr.;  sodii  chloridi,  lo  gr.; 
distilled  water,  i  c.c.  This  is  put  up  in  hermetically  sealed  am- 
poules, each  containing  i  c.c.  of  the  solution,  which  is  sufficient  for 
an  injection.  Bier  regards  cocaine  as  the  most  dangerous  and 
tropacocaine  the  safest,  and  this  latter  he  employs  in  doses  of  H 
to  I  grain.  The  syringe  employed  must  be  easily  sterilized  and 
with  a  capacity  of  at  least  2  c.c.  A  long  platinum  needle  is  best. 
A  special  glass  s\Tinge  with  needle  for  this  injection  can  be  readily 
secured. 

Technic. — The  patient's  back,  the  instruments,  the  solution,  the 
operator's  hands,  are  duly  prepared.  The  needle  is  attached  to  the 
s\Tinge  and  the  contents  of  an  ampoule  aspirated  and  the  needle 
detached.  The  patient  sits  bending  forward  to  make  the  lumbar 
spines  more  prominent  and  to  enlarge  the  intervertebral  foramen 
which  is  to  be  traversed  by  the  needle.  Locate  the  ihac  crests  and 
mark  their  position  -^-ith  the  finger  nails.  The  line  connecting  the 
highest  points  of  the  Diac  crests  intersects  the  fourth  lumbar  spine 
the  tip  of  which  is  next  to  be  located  in  the  middle  line.     The  tip  of 


SPINAL   ANESTHESIA 


23 


the  next  spine  above  the  third  is  now  marked  and  between  these 
two  points  the  puncture  is  made.  Hold  the  left  index  finger  on  the 
third  lumbar  spine.  Hold  the  unattached  needle  in  the  right 
hand,  and  enter  its  point  just  below  the  third  lumbar  spine  a  little 
to  the  right  of  the  middle  line,  and  push  it  slightly  upward  and  in- 
ward at  an  angle  sufficient  to  meet  the  spinal  membranes  in  the 
middle  line.  Pushing  the  needle  steadily  upward  and  inward,  it 
can  be  felt  to  reach  the  resisting  ligamentumsubflava  and,  finally,  the 
puncture  of  the  membranes  is  announced  by  the  flow  of  spinal  fluid 
from  the  needle.  Hold  the  finger  over  the  outlet  until  the  syringe 
can  be  attached;  then  let  sufficient  fluid  run  in  the  syringe  to  make 
2  c.c;  in  other  words,  make  a  mixture  in  the  syringe  containing 
equal  parts  of  stovaine  solution  and  spinal  fluid.  The  clear  spinal 
fluid  becomes  milky  on  meeting  the  anesthetic  solution.  Now 
slowly  inject  the  mixture,  and  when  the  syringe  is  emptied,  with- 
draw the  needle  with  a  rapid  movement  and  seal  the  puncture 
with  collodion.     It  will  require  no  further  attention. 

Have  the  patient  lie  down  and  now  prepare  for  the  operation. 
In  ten  to  fifteen  minutes  the  anesthesia  begins.  The  patient 
complains  of  a  pricking  sensation  in  the  feet  and  numbness  in  the 
legs.  A  pinch  or  a  pin  prick  wiU  be  felt  but  will  not  be  painful.  If 
the  pain  becomes  too  severe  in  the  course  of  the  operation,  a  little 
chloroform  or  ether  can  be  employed.  If  the  anesthetic  zone  does 
not  extend  high  enough,  incline  the  body  slightly,  head  downward. 
During  the  operation  the  patient's  face  is  likely  to  be  congested  and 
his  head  will  throb.  Afterward  there  is  likely  to  be  a  severe  head- 
ache for  a  little  while  and  perhaps  some  nausea. 

The  site  of  puncture  may  be  numbed  with  cocaine,  so  that  the 
spinal  injection  is  painless.  If  the  point  of  the  needle  engages 
against  the  vertebra,  withdraw  slightly  and  change  the  direction 
as  the  judgment  dictates.  The  most  common  mistake  is  in  di- 
recting the  needle  too  much  upward.  Only  very  rarely  will  one  fail 
to  reach  the  spinal  canal  if  the  landmarks  are  well  defined. 

Jonnesco  has  been  the  great  advocate  of  this  form  of  anesthesia 
and  reports  its  use  in  2500  cases.  He  believes  now  more  than  ever 
that  unlike  ether  and  chloroform  there  is  no  contra-indication  and 
that  it  is  che  anesthetic  of  the  future.     (Presse  Medical,  Oct.,  1913). 


24  ANESTHESIA 

Murphy  referring  to  this  and  other  of  the  newer  forms  of  anesthesia 
wisely  suggests  that  considering  the  safety  and  simplicity  of  the 
ether  drop  method  the  mass  of  the  profession  should  await  larger 
experiences  by  those  who  originate  and  are  best  fitted  to  work  out 
the  destiny  of  these  newer  forms.  (Practical  ^Medical  Series, 
Vol.  II,  1914.) 


CHAPTER  IV 

SUTURES;  METHODS,  AND  MATERIALS 

Sutures  are  applied  for  the  purpose  of  maintaining  the  coapta- 
tion of  divided  structures.  This  is  necessary  to  facilitate  repair 
and  restore  function.  Suturing  serves  the  additional  purpose  of 
checking  hemorrhage  from  the  smaller  vessels.  There  is  no  part 
of  the  surgeon's  technic  that  deserves  more  attention  than  the  se- 
lection and  use  of  sutures.  It  is  of  special  importance  to  the  emer- 
gency surgeon  who  faces  infection  in  every  direction.  His  suturing, 
however,  he  may  absolutely  control  and  make  aseptic,  and  this 
may  be  the  only  difference  between  success  and  failure. 

Various  materials  are  used,  some  quite  commonly,  others  rarely 
and  for  a  certain  purpose;  catgut,  silk,  silkworm-gut,  silver  wire, 
kangaroo  tendon,  and  horsehair.  The  three  first  named  will  meet 
all  the  requirements  of  the  emergency  surgeon. 

No  material  is  available  which  does  not  have  a  certain  strength 
and  which  cannot  be  made  aseptic.  For  emergency  work,  these 
materials  must  be  already  prepared.  The  creation  of  a  proper 
suture  from  the  raw  material  is  a  matter  of  time  and  care. 

The  general  practitioner  will  do  better  to  buy  his  sutures  pre- 
pared in  form  available  for  immediate  use,  being  first  assured  that 
they  come  from  a  reliable  source  and  are  put  up  in  a  manner  to 
keep  them  sterile.  Much  suture  material  on  the  market  has  neither 
of  these  qualifications. 

Silk  has  the  advantage  of  lending  itself  to  emergency  steriliza- 
tion by  boiling  and  immersion  in  an  antiseptic  solution,  nor  is  it 
readily  contaminated  when  once  sterile;  but  it  should  not  be  boiled 
in  soda  solution,  which  makes  it  brittle.  It  has  the  disadvantage 
of  not  being  absorbable.  It  may  be  used  in  buried  sutures,  but  its 
usefulness  in  that  respect  grows  more  and  more  Umited  as  the  art 
of  sterilization  and  preservation  of  catgut  improves.     It  may  be 

25 


26  SUTURES,   METHODS    AND   MATERIALS 

used  in  interrupted  skin  sutures,  suture  of  nerves,  of  tendon,  and  of 
the  intestine,  but  muscular  tissues  do  not  tolerate  it. 

Catgut  is  the  ideal  material  for  the  buried  suture.  The  chromi- 
cized  gut  has  ample  strength  and  is  so  prepared  as  to  resist  absorp- 
tion in  a  certain  tissue  for  an  approximate  time;  but  it  should  be  re- 
membered that  occasionally  chromicized  gut  becomes  practically 
unabsorbable  and,  acting  as  a  foreign  body,  gives  rise  to  persistent 
sinuses.  With  a  little  attention  to  this  detail,  a  suture  may  be 
selected  which  will  resist  absorption  until  repair  is  complete.  Plain 
catgut  can  be  used  in  those  tissues  only  which  rapidly  unite.  It  is 
ideal  for  suturing  the  peritoneum  and  for  ligating  vessels  except  the 
very  large- ones.  It  is  very  easily  contaminated.  Where  there  is 
pus  it  should  never  be  used  as  a  buried  suture.  The  three  qualities 
which  the  catgut  suture  must  possess  are :  sterility,  tensile  strength, 
and  absorbability.  If  a  certain  brand  of  catgut  produces  stitch- 
abscess  persistently;  if,  properly  used,  it  still  breaks  inopportunely; 
if  it  refuses  to  be  absorbed,  then  there  is  something  wrong  with  its 
manufacture.  The  occasional  surgeon  lacking  opportunity  to  test 
all  the  brands,  must  therefore  fall  back  upon  the  manufacturer's 
reputation  and  guarantee.  Absorption  of  catgut  occurs  in  this 
manner:  at  first  the  fibers  untwirl  and  grow  loose  and  finally  become 
pulpy  at  which  stage  the  suture  has  no  tensile  strength  and  is  a 
foreign  body  which  is  gradually  replaced  by  connective  tissue,  a 
process  which  is  sometimes  exceedingly  slow.  Even  sterile  catgut 
once  degenerated  into  a  gelatinous  compound  becomes  a  nidus 
for  bacterial  growth.  Absorbability  is  therefore  as  important  as 
sterility. 

Watery  solutions  and  certain  chemicals  as  bichloride  render  cat- 
gut brittle  and  weak. 

Silkworm-gut  is  very  strong,  non-elastic,  non-absorbable,  readily 
sterilized,  and  is  much  employed  where  the  wound  is  large  and  deep 
and  the  tissues  tend  strongly  to  spread  apart.  Most  surgeons  employ 
it  to  suture  the  skin  and  fascia  after  laparotomy.  It  should  be 
kept  in  various  sizes. 

The  pagenstecher  celluloid  linen  is  in  high  favor  with  some  sur- 
geons; it  is  more  flexible  than  silkworm-gut  and  absorbs  moisture 
without  softening. 


THE   CONTINUOUS    SUTURE 


27 


Fig.    i2. — The  quilted  suture. 
{Moullin.) 


The  methods  of  suturing  adapted  to  emergency  surgery  are  the 
interrupted  suture  and  the  continuous  suture.  Others  occasionally 
employed  in  general  surgery  are  the  quilled,  the  quilted  (Fig.  12), 
the  twisted,  and  the  button  sutures. 

The  continuous  suture  is  used  in  aseptic 
wounds  only.  Therefore,  accidental  wounds 
will  only,  on  rare  occasions,  permit  its  em- 
ployment. It  has  the  advantage  of  being 
very  rapidly  applied,  but  is  less  sure  than 
the  interrupted  suture.  A  little  practice  is 
essential,  for  it  is  not  altogether  easy.  Its 
success  depends  largely  upon  the  assistant. 
This  is  the  mode  of  making  the  con- 
tinuous suture:  Commence  by  passing  the 
suture   at   the  upper  angle  of  the  wound. 

Make  three  successive  knots.     Two  are  sufficient  for  catgut.     The 
short   thread   is   caught  in  forceps  and  retained  till  the  suture  is 

completed,  at  which   time   it   is  cut  off 
close  to  the  knot  (Fig.  13). 

The  needle  traverses,  successively  and 
obliquely,  first  the  one  lip  of  the  wound 
and  then  the  other;  each  time  the  assist- 
ant seizes  the  thread  at  the  point  of 
emergence,  and  holds  it  tightly  until  the 
surgeon  makes  a  new  point  of  emergence, 
when  the  assistant  takes  a  new  hold. 
In  this  manner,  the  tension  of  the  suture 
is  made  absolutely  uniform. 

The  mode  of  arrest  of  the  continuous 
suture    is    important.     In    making    the 
terminal  knot,  the  suture  must  not  be 
Fig.  13.— Method  of  making  a  allowcd  to  rclax.      To  accompUsh  this, 
continuous  suture.    Assistant  ^j^g  surgcon  sHps  the  indcx  finger  in  the 

holding   the  suture  tight  while  the  ^.  jn 

needle  is  passed  again.    {Veau.)     last  loop  mstcad  of  puUmg  the  thread  all 

the  way  through,  as  was  done  with  all 
the  others.  Traction  with  this  finger  holds  the  line  of  suture 
tight  while  the  terminal  thread  on  the  one  side  is  knotted  three 
times  with  this  loop  on  the  other  side  (Figs.  14,  15). 


28 


SUTURES,  METHODS  AND  MATERIALS 


Fig.  14. — Completing  the 
continuous  suture;  holding 
the  suture  tight  with  finger 
through  loop  while  getting 
ready  to  tie.      (Veau.) 


Fig.  15. — Method  of  ty-  Fig.  16. — Continuous  su- 
ing completed  continuous  ture  interrupted  in  its  course 
suture.      {Veau.)  (Hartmann.) 


Fig.  17.- — Method  of 
interrupting  the  con- 
tinuous suture  in  its 
course.  Needle  passed 
back  under  last  loop. 
{Veau.) 


Fig.  18.— T  h  e 
needle  has  been 
passed  through  the 
loop  which  is  drawn 
down  tight  and  the 
suture  proceeds  as 
before.     (,Veau.) 


Fig.   10. — Method  of  passing  deep  inter- 
rupted sutures.      (Veau.) 


THE  INTERRUPTED   SUTURE 


29 


If  the  continuous  suture  is  long,  its  stability  is  insured  by  crossing 
the  threads  at  the  middle  of  the  line  of  suture  (Fig.  16).  The 
suture  is  thus  interrupted  at  its  middle  in  this  manner:  the  needle  is 


Fig.  20. — Tying  interrupted  sutures. 
Forceps  everting  lips  of  wound  to  se- 
cure coaptation.      (Veau). 


Fig.  21. — Method      of      passing 
superficial  sutures.      (Veau.) 


simply  passed  back  under  the  last  loop,  at  the  time  care  being  taken 
that  the  suture  does  not  slip.     The  succeeding  steps  are  the  same 
as  before  (Figs.  17,  18).     The  suture 
completed,  the  loose  ends  are  cut  off 
close  to  the  knot. 

The  interrupted  sutixre]^is  generally 
employed  in  suturing  the  skin,  and 
may  be  of  silk,  silkworm-gut,  silver, 
etc.  It  must  not  be  absorbable. 
These  sutures  may  be  placed  deeply 
or  superficially,  in  the  one  case  where 
there  is  much  tension,  in  the  other 
for  mere  approximation.  The  deep 
sutures  are  placed  two  or  three  cen- 
timeters apart. 

The  needle  is  entered  one  centimeter  from  the  edge  and  emerges 
the  same  distance  from  the  other  side.     The  thread  is  concealed 


Fig, 


IfifU'  to  do  it. 


Hou  not  to  do  U 


22. — Sutures  must  not  be  tied 
too  tight.     (Moullin.) 


30 


SUTURES,  METHODS  AND  MATERIALS 


through  most  of  its  extent  (Fig.  19).  None  is  tied  until  all  are 
passed.  The  lips  of  the  wound  are  brought  together  as  the  knots 
are  tied  (Fig.  20). 

A  few  superficial  catgut  sutures  may  be  necessary  if  the  deep 
sutures  do  not  completely  approximate.  They  are  passed  through 
the  thickness  of  the  skin  alone  and  very  close  to  the  edge  of  the  wound 
(Fig.  21). 

No  knot  should  be  drawn  too  tight.  It  may  interrupt  the  circu- 
lation and  defeat  repair.     The  knot  should  be  made  to  one  side  of, 

and  not  over  the  wound  (Fig.  22). 

If  all  goes  well,  the  sutures  may  be  removed 
toward  the  eighth  day.  Remaining  too  long, 
they  favor  infection. 

MetJiods  of  RefTWving  Sutures. — Seize  the  loop 
with  a  dissecting  forceps  held  in  the  left  hand. 
With  a  pointed  scissors  divide  the  thread 
close  to  the  skin,  being  careful  not  to  cut  be- 
tween the  knot  and  the  forceps,  else  one  will 
be  trying  to  pull  the  knot  through  the  skin. 

Suppose,  in  spite  of  care,  infection  occurs. 
The  temperature  reaches  100)2°  on  the  follow- 
ing day.  On  the  second  day  following,  it  is  a 
little  higher.  Upon  removal  of  the  dressing, 
the  skin  around  the  wound  is  found  to  be 
The  subcuticular  suture;  reddened  and  swollen.  Remove  two  or  three 
method  of  passing  and  of  the  middle  suturcs  at  once.  Secure  drain- 
tightening.      {VeaU.)  J  ^     J  •  rr^V-  -11  11 

age  and  use  a  wet  dressmg.  1  his  will  usually 
check  the  infective  process  and  pus  formation. 

The  subcuticular  suture  is  of  great  service  in  aseptic  operative 
wounds,  wherever  it  is  especially  desired  to  prevent  a  scar.  It  is 
made  in  this  manner: 

Introduce  a  smaU  needle  threaded  with  No.  i  catgut,  J^ 
inch  above  the  upper  angle  of  the  wound,  and  let  it  penetrate  the 
skin  and  emerge  exactly  at  the  upper  angle.  It  next  penetrates 
the  face  of  the  skin  incision,  taking  a  bite  first  on  one  side  and  then 
on  the  other  exactly  opposite  (Fig.  23).  At  the  end,  the  needle 
traverses  the  skin  at  the  lower  angle  of  the  wound  in  the  same 


THE    SUBCUTICULAR   SUTURE  3 1 

manner  as  it  entered  at  the  upper  angle;  the  sutures  are  then 
tightened  (Fig.  24)  until  the  edges  of  the  wound  are  exactly  coapted. 
The  ends  are  secured  from  slipping  either  by  knotting  or  by  pasting 
them  down  with  collodion  or  adhesive  plaster.  If  the  thread  is  not 
absorbed,  it  may  be  removed  about  the  sixth  day  by  clipping  one 
end  close  to  the  skin  and  then  gently  drawing  it  from  the  other 
end. 

Cannaday  uses  pagenstecher  linen  and  after  starting  the  suture 
secures  the  loose  end  by  a  half  bow  knot.  The  terminal  thread  is 
secured  in  the  same  way  and  slipping  or  loosening  is  thus  prevented. 


CHAPTER  V 
DRAINAGE 

Drainage  may  justly  be  regarded  as  a  matter  of  antisepsis.  It 
prevents  sepsis  by  creating  a  current  which  moves  away  from  the 
wound,  and  by  depriving  the  bacteria  of  their  chief  pabulum — the 
wound  exudates.  Drainage  facilitates  repair  by  relieving  tension. 
In  the  same  manner  it  relieves  pain.  But  when  these  points  are 
made  the  whole  is  said,  for  drainage  is  by  no  means  an  unmixed 
good.  On  the  contrary,  it  is  a  necessary  evil  and  for  these  reasons: 
in  reality  it  is  a  foreign  body;  it  necessitates  frequent  renewal  of 
dressings;  it  may  injure  granulations;  it  keeps  the  wound  open  and 
delays  healing;  in  the  abdominal  cavity  it  sometimes  predisposes  to 
fistula,  hernia,  and  intestinal  obstruction.  Nor  is  the  profession  by 
any  means  of  one  mind  regarding  the  indications  and  contra-in- 
dications.  It  is  a  matter  in  which  one  cannot  be  dogmatic.  The 
rule  of  practice  must  of  necessity  vary  with  the  patient,  the 
operator,  and  the  environment. 

The  emergency  surgeon,  the  general  practitioner,  will  more  often 
drain  than  the  hospital  surgeon  in  formal  operations.  And  this 
leads  to  the  fundamental  principles  involved. 

Aseptic  wounds,  as  a  rule,  do  not  require  drainage. 

Infected  wounds  or  those  suspected  should  always  be  drained,  for 
infection  of  any  kind  demands  an  outlet. 

Accidental  wounds  are  presumed  to  be  infected,  whereas  operative 
wounds  are  presumed  to  be  aseptic. 

As  an  exception  to  the  rule  that  aseptic  wounds  do  not  require 
drainage,  note  that  those  in  which  there  is  of  necessity  much  post- 
operative oozing  do  better  with  temporary  drainage.  Examples: 
large  amputation  stumps,  and  breast  amputations. 

Suspected  wounds  are  not  drained  after  the  third  day,  if  infection 
has  not  made  its  appearance  nor  seems  likely  to  develop. 

Infections  are  drained  as  long  as  there  are  any  discharges. 

32 


WICK   AND   CIGARETTE   DRAINS 


33 


The  means  of  drainage  in  emergency  practice  are  three:  tubes, 
gauze,  and  open  wounds;  or  combinations  of  the  three. 

Rubber  tubes,  the  larger  the  better  in  proportion  to  the  infected 
cavity,  are  the  best  means  of  draining  large  cavities,  and  are  the 
sole  means  of  draining  abscess  cavities  and  large  infections.  They 
should  be  fenestrated,  and  may  be  improvised  from  rubber  catheters. 
Wherever  used,  they  must  be  cut  off  close  to  the  surface  and,  in  the 
case  of  cavities,  must  be  anchored  by  suture  or  safety  pins. 

Gauze. — Plain  sterile  gauze,  which  drains  by  capillarity,  is  an 
efficient  means  of  removing  exudates,  such  as  serum  and  blood.  It 
has  the  additional  advantage  that  in  appropriate  cases  it  may  be  at 
the  same  time  employed  for  hemostasis.  It  has  the  disadvantage 
that  it  soon  ceases  to  drain,  acquires  adhesions,  and  is  painful  to 
remove. 

Tubal  and  capillary  drainage  are  advantageously  combined  in  the 
"gauze  wick"  and  ''cigarette  drain."  A  "gauze  wick"  drain  is 
made  by  splitting  a  tube  of  the  required  length  and  fitting  it  loosely 
with  a  strip  of  gauze.  When  the  tube  is  carried  to  the  bottom  of  the 
cavity,  the  projecting  gauze  is  brought  in  contact  with  the  oozing 
surface,  is  hemostatic,  and  finally  may  be  removed  without  dis- 
turbing the  tube.  A  cigarette  drain  acts  on  the  same  principle  and 
is  essentially  a  series  of  wick  drains,  one  within  the  other.  To  make 
a  "cigarette  drain,"  take  a  lo-inch  square  of  rubber  tissue,  cover 
it  with  four  or  five  layers  of  sterile  gauze,  and  roll  the  whole  into  a 
slender  cylinder. 

"Wick"  and  "cigarette"  drains  should  be  removed  on  the  second 
or  third  day.  If  infection  is  present  at  that  time,  a  tube  should  be 
substituted;  a  tube  must  be  employed  if  infection  develops  later. 
Tubes  employed  in  the  drainage  of  pus  cavities  should  be  removed, 
cleaned,  and  reinserted  at  least  every  third  day,  and  are  to  be 
shortened  pari  passu  with  granular  repair. 

As  has  been  said,  an  open  wound  is  a  means  of  drainage,  and  for 
that  reason  accidental  incised  wounds  are,  as  a  rule,  not  completely 
sutured.  Lacerated  wounds  not  repairable  need  no  other  drainage 
than  that  afforded  by  the  gauze  dressings. 

To  note  briefly  some  examples  of  drainage:     Abscesses  are  always 
to  be  drained  with  tubes. 
3 


34  DRAINAGE 

Acute  spreading  infections  are  to  be  drained  with  tubes. 

Accidental  incised  wounds  are  to  be  drained  with  tubes,  or  simply 
by  rubber  tissue  if  the  wound  is  small. 

Operative  wounds  of  the  soft  parts  in  emergency  practice  are  often 
best  drained  superficially — all  the  layers  are  completely  closed  ex- 
cept the  skin.  A  few  strands  of  catgut  between  the  lips  of  the 
wound  will  often  be  all  that  is  necessary  for  drainage  and  has  the 
advantage  of  requiring  no  change  of  dressing. 

An  empyema  or  purulent  peritonitis  must  be  drained  with  tubes. 

Many  thoracic  and  abdominal  conditions  are  to  be  drained  with 
the  wick  or  cigarette  drain.  If  there  is  no  probability  of  infection, 
if  there  is  not  much  oozing,  do  not  drain  at  all. 

In  compound  fractures  and  compound  dislocations  drain  only  the 
skin  wound.  If  infection  develops,  deep  drainage  must  be  substi- 
tuted. 

Further  details  will  be  given  in  connection  with  the  various 
operations  requiring  drainage. 


CHAPTER  VI 

DRESSINGS,  BANDAGES,  SPLINTS 

The  emergency  surgeon  needs  no  great  variety  of  dressing  materials. 
If  he  has  sterile  gauze  and  sterile  absorbent  cotton,  he  can  efficiently 
meet  all  the  indications  so  far  as  dressings  are  concerned;  for  these 
materials  furnish  in  the  highest  degree  the  properties  which  pertain 
to  a  good  dressing.  A  good  dressing  is  sterile,  absorbent,  and  pro- 
tective. It  conducts  the  exudates  away  from  the  wound  and 
prevents  the  approach  of  infective  germs.  For  emergency  work 
it  is  better  to  buy  these  materials  already  prepared  and  ready  for 
instant  use.  But  they  must  come  from  a  reliable  source.  Even  the 
most  trustworthy  products  are  not  always  aseptic.  In  major  opera- 
tions they  should  be  re-sterilized  if  possible.  Of  course  the  surest 
way  to  sterilize  is  by  steam.  Still  these  materials  exposed  to  the 
high  heat  in  the  closed  oven  of  the  kitchen  stove  might  reasonably 
be  expected  to  be  germ  free.  Medicated  gauze  is  often  useful  but  not 
essential,  nor  so  much  employed  as  formerly.  It  may  be  improvised 
by  dusting  the  plain  sterile  gauze  with  the  preferred  antiseptic 
powder  at  the  time  of  dressing.  For  that  matter  all  of  the  dressing 
may  be  improvised  for  temporary  use  from  muslin,  linen,  or  cheese- 
cloth. Towels  or  sheets  may  be  prepared  by  boiling  for  fifteen 
minutes  in  soda  solution,  rinsing  in  cold  sterile  water,  wringing  out 
the  water,  and  completing  the  drying  process  on  the  stove.  From 
these  materials  one  may  provide  not  only  dressings,  but  compresses 
and  sponges  for  the  operation. 

An  aseptic  wound  requires  that  the  dressing  be  dry;  whatever  slight 
serous  oozing  there  may  be  is  thus  rapidly  absorbed. 

Septic  wounds  require  a  dressing  moist  with  some  antiseptic  solu- 
tion. For  one  thing,  the  moist  gauze  conforms  better  to  the  irre- 
gluarities  of  a  lacerated  wound.  Again,  the  antiseptic  agent  exerts 
some  slight  destructive  effect,  perhaps,  upon  the  germ  already  in  the 

35 


36  DRESSINGS,  BANDAGES,    SPLINTS 

wound  and  is  a  more  effective  screen  against  those  trying  to  get  in. 
Moist  boracic  and  bichloride  gauze  are  the  most  commonly  used. 
If  acute  sepsis  is  present,  sterile  gauze  saturated  with  peroxide 
of  hydrogen  is  to  be  recommended.  As  an  antiseptic  dressing  New- 
man particularly  recommends  gauze  saturated  with  subgallate  of 
bismuth.     (Lancet,  June  28,  1913.) 

The  dressings  must  be  ample.  Too  often  an  aseptic  operative 
wound  eventually  becomes  infected  merely  because  not  sufficiently 
protected.  The  dressings  must  not  only  be  thick  enough,  but  they 
must  extend  widely  beyond  the  limits  of  the  wound.  It  is  a  poor 
dressing,  indeed,  if  one  can  lift  its  edges  and  inspect  the  wound. 

The  frequency  of  redressing  is  variable.  In  general,  the  fewer 
dressings  the  better.  The  aseptic  operative  wound  should  need 
but  two  dressings.  The  original  dressing  is  removed  when  the 
sutures  are  taken  out  on  the  eighth  to  the  tenth  day. 

The  septic  wound  may  need  to  be  dressed  daily.  A  wound  prob- 
ably infected  but  not  septic,  one  in  which  a  drainage  tube  was  used, 
will  need  to  be  dressed  on  the  second  to  the  fifth  day,  when  the 
drainage  tube  is  removed.  The  frequency  of  dressing  thereafter 
will  depend  upon  the  degree  of  sepsis.  In  changing  the  dressing  of  ^ 
sterile  wound,  every  precaution  must  be  taken  against  infection. 
Many  a  fine  operative  result  is  spoiled  by  carelessness  in  changing 
the  dressing.  The  hands,  the  solutions,  the  instruments,  must  be 
prepared. 

It  is  good  practice  in  the  case  of  any  kind  of  wound  to  change  the 
dressing  whenever  soiled,  for  sterile  exudates  may  become  good  cul- 
ture media.  One  may,  however,  follow  Senn's  suggestion,  dusting 
the  saturated  area  with  boro-salicylic  acid  or  other  antiseptic  powder 
and  covering  with  an  additional  layer  of  cotton  and  bandage. 

Pain  or  rise  of  temperature  after  the  first  twenty-four  hours  is 
always  an  indication  to  change  the  dressing  and  inspect  the  wound. 
A  loosened  dressing  calls  for  renewal.  The  dressing  that  slips  or 
rubs  is  a  very  poor  one.  When  the  dressings  are  adherent  to  the 
wound  surface,  they  are  to  be  saturated  with  warm  sterile  water  or 
with  peroxide  of  hydrogen.  The  latter  is  excellent  when  the  dressing 
contains  dried  blood.  When  changing  the  dressings  any  undue 
movement  of  the  parts  must  be  avoided.     The  principles  of  support 


TIIK    ROLLER  BANDAGP: 


37 


and  functional  rest  are  not  to  be  neglected  even  for  the  short  time 
the  dressing  is  off. 

BANDAGES 

The  gauze  roller  is  porous,  absorbent,  protective,  and  therefore 
a  part  of  the  dressing.  The  wound  is  covered  with  gauze,  the  gauze 
is  amply  covered  with  absorbent  cotton,  and  the  whole  retained  by  a 
smooth  bandage,  uniformly  compressive.  Bandaging,  as  the  older 
doctors  knew  it,  is  almost  a  lost  art,  for  the  gauze  roller  is  accommo- 


FiG.  25. — Double  spicas  of  groin.     (Heath.) 

dating  and  adhesive  plaster  convenient.  One  may  give  a  dressing 
the  appearance  of  stability  without  its  being  in  reality  efficient.  The 
bandage  must  be  so  applied  that  it  will  not  slip  and  will  remain 
closed  at  either  end.  It  must  extend  well  beyond  the  limits  of  the 
subjacent  dressing,  and  in  the  case  of  the  limbs  must  reach  beyond 
the  next  joint  above.  For  example:  a  dressing  of  the  foot  must 
extend  above  the  ankle;  of  the  leg,  above  the  knee;  of  the  forearm, 
above  the  elbow.  In  the  region  of  the  groin  a  double  spica  should 
be  employed,  extending  well  up  over  the  abdomen,  and  down  over 
the  thighs  (Fig.  25). 


38  DRESSINGS,   BANDAGES,    SPLINTS 

A  bandage  of  the  neck,  that  it  may  not  slip,  must  include  the  head 
and  shoulder. 

The  dressings  of  the  abdomen  and  thorax  are  best  held  in 
place  by  vn.de  bands  of  flannel  firmly  applied  and  secured  by 
safety  pins,  and  whose  edges  are  held  down  by  suspenders  and 
perineal  strips. 

To  apply  a  bandage  to  a  limb,  for  example:  stand  in  front  of  the 
patient.  That  the  bandage  may  unroll  more  freely,  place  the  free 
end  of  the  bandage  in  contact  with  the  dressing  by  its  outer  surface, 
and  hold  the  roller  to  the  outside  of  the  limb — in  the  right  hand  for 
the  left  limb,  in  the  left  hand  for  the  right  hmb.  Each  turn  should 
overlap  about  one-half  the  previous  turn.  To  maintain  uniform 
pressure  in  spite  of  the  limb's  change  in  contour  as  the  bandage 
progresses  certain  modifications  of  the  ordinary  spiral  or  circular 
turns  are  necessary — the  "spiral  reverse"  and  "figure-of-eight" 
are  to  be  employed.  The  "spiral  reverse"  is  used  where  the  cir- 
cumference rapidly  changes,  as  in  approaching  the  calf  of  the  leg; 
if  it  is  not  made,  one  edge  of  the  bandage  is  tight  and  the  other  edge 
loose.  To  make  the  reverse,  the  bandage  is  slackened  when  the 
outer  side  of  the  limb  is  reached  and  a  half  rotation  is  made,  by  a 
twist  of  the  wrist.  The  beginner  is  often  observed  to  make  a  com- 
plete turn  of  the  bandage  instead  of  a  hah  turn.  This  tightens  the 
bandage,  but  does  not  give  uniform  compression.  In  making  the 
turn,  the  thumb  of  one  hand  steadies  the  lower  edge  of  the  bandage, 
while  the  other  hand  makes  the  hah  turn  mentioned.  The  reverse 
should  always  be  made  in  the  same  vertical  line  and  should,  if 
practical,  correspond  to  the  wound,  in  order  to  give  it  the  ad- 
vantage of  the  extra  thicknesses.  The  bandage  is  then  continued 
on  around  the  leg  until  the  outside  is  again  reached  when  the 
reverse  is  repeated.  The  ''figure-of-eight,"  the  second  means  of 
taking  up  the  slack,  is  most  useful  in  the  region  of  the  joints,  and 
at  the  calf. 

Bandage  for  the  Foot. — (Fig.  26.)  Begin  near  the  toes  with  spiral 
turns,  reversed  as  the  ankle  is  neared.  Encircle  the  ankle  with  the 
"figure-of-eight"  turns  and  continue  the  spiral  turns  up  the  leg. 
If  it  is  desired  to  cover  the  heel,  the  first  turn  should  cross  the  upper 
part  of  the  heel  and  over  the  front  of  the  joint;  the  second  turn 


BANDAGE   FOR   THE   FOOT 


39 


overlaps  the  lower  half  of  the  first;  the  third  turn  overlaps  the 
upper  half  of  the  first.     The  roller  on  the  third  turn  reaches  the 


Fig.  26. — Bandage  of  foot.     (Heath.) 


Fig.   27. — Bandage  of  foot.     Heel  covered. 
(Heath.) 


dorsum  of  the  foot,  and  is  carried  obliquely  across  toward  the  little 
toe  and  the  foot  is  covered  by  spiral  turns  which  progress  upward,  or 
it  may  be  applied  as  indicated  in  Fig.  27.     The  spica  of  the  foot  is 


Fig.  28. — Spica  of  foot.     (Stewart.) 

indicated  by  Fig.  28.     If  it  is  desired  to  cover  the  toes,  back  and  forth 
folds  extending  from  in  front  of  the  ankle  to  a  corresponding  point 


40 


DRESSINGS,  BANDAGES,    SPLINTS 


Fig.  29.  Fig.  30. 

Bandage  of  leg.      (Heath.) 


Fig.  31. — Figure  of  "8"  of  knee. 
(Heath.) 


Fig.  32, — Bandage  of  knee- 
Spiral  reverse.     (Heath.) 


BANDAGE  FOR  THE  LEG  AND  KNEE 


41 


on  the  sole  may  be  run  on  and  held  in  place  by  additional  circular 
turns  about  the  foot. 

Bandage  for  the  Leg. — Begin  above  the  ankle  with  spiral  turns, 
progress  upward  and,  as  the  calf  is  approached,  use  the  reverse 
(Fig.  29);  or  a  ''figure-of-eight"  may  be  employed  throughout 
(Fig.  30),  but  the  latter  does  not  fit  so  well  about  the  calf  as  the 
former. 

Bandage  for  the  Knee. — This  may  be  a  continuation  of  the  leg 
bandage  or  may  include  the  knee  alone;  in  either  case  it  is  a  "figure- 
of-eight"  running  from  below  the  patella  around  the  outer  side  of 


Fig.  zz- — Spica  of  groin.     {Heath.) 


the  knee,  across  and  up  behind  the  knee  to  the  inner  condyle.  Now 
make  circular  turns  about  the  thigh.  From  the  inner  condyle, 
cross  the  knee  obliquely  downward  and  outward  to  the  head  of  the 
fibula;  make  a  circular  turn  about  the  leg  below  the  knee,  and,  when 
the  patellar  line  is  reached,  begin  over  again  the  "figure-of-eight," 
lapping  the  preceding  one  (Figs.  31,  32). 

Bandage  for  the  Groin. — Begin  at  the  inner  end  of  the  groin  and 
carry  the  roller  upward  and  outward  to  the  iliac  crest,  around  to  the 


42 


DRESSINGS,  BANDAGES,   SPLINTS 


Fig.  34- — Bandage  for  breast.     {Heath.) 


Fig.  35. — Bandagejor  both  breasts      {Heath.) 


DOUBLE   SPICA  FOR   GROIN 


43 


opposite  crest,  obliquely  across  the  belly  toward  the  pubes,  around 
the  thigh  to  the  starting-point.  Repeat  these  turns  as  often  as 
necessary,  each  overlapping  the  preceding  (Fig.  33). 


Fig.  36. — Finger  bandage. 
(Heath.) 


Fig.  37. — Spica  of  the  thumb. 
(Heath.) 


The  Double  Spica. — The  right  groin  is  bandaged  as  described 
above.  When  the  roller,  carried  about  the  body,  reaches  the  left 
side  of  the  pelvis,  it  leaves  the  original  track,  follows  the  left  groin 


Fig.  38. — Bandage  for  all  the  fingers.     (Heath.) 

downward  and  thence  around  the  thigh;  is  then  carried  across  the 
belly  and  around  the  body  to  the  right  groin  again.  These  band- 
agesmay  be  applied  with  the  patient  standing  or  with  the  pelvis 


44 


DRESSINGS,  BANDAGES,    SPLINTS 


on  the  Volkman  rest.  For  the  perineum  and  pelvis,  one  may  use 
the  "  St.  Andrew's  cross,"  which,  after  a  turn  about  the  body,  crosses 
over  the  left  groin,  behind  the  left  thigh  just  below  the  nates,  ob- 
liquely upward  across  the  perineum,  over  the  right  groin  toward 
the  right  iliac  spine.  It  then  passes  around  the  left  iliac  spine  and 
down  the  left  groin  across  the  perineum. 

Bandage  for  the  Breast. — Begin  with  two  or  three  turns  about  the 
chest;  carry  the  roller  across  the  breast  to  the  sound  side;  next 


Fig.  39. — Bandage  for  arm.     {Heath.) 


carry  it  under  the  affected  breast  to  the  opposite  shoulder;  across 
the  back  to  the  breast  again  and  up  over  the  shoulder;  and  then 
around  the  body  again  (Fig.  34).  Both  breasts  may  be  bandaged 
at  the  same  time,  carrying  the  turns  about  first  one  breast  and  then 
the  other  (Fig.  35). 

Bandage  for  the  Finger. — Begin  with  two  or  three  turns  about  the 
wrist,  and  then  carry  the  bandage  across  the  dorsum  of  the  hand 
and  base  of  finger,  and  run  it  down  to  the  tip  by  two  or  three  oblique 
turns;  bandage  from  the  tip  to  the  base  by  regular  circular  turns. 


SPICA  FOR   THE   SHOULDER 


45 


From  the  base,  carry  the  bandage  across  the  dorsum  of  the  hand 
and  around  the  wrist  again  (Fig.  36). 

Bandage  for  the  Thumb. — Begin  at  the  ulnar  side  of  the  wrist  and 
carry  the  bandage  across  the  dorsum  around  the  wrist  for  a  turn  or 
two.  Next  carry  the  roller  obliquely  across  the  dorsum  of  the 
hand  and  toward  the  radial  side  of  the  thumb,  as  near  the  tip  as 
desired.  Secure  by  a  circular  turn  and  then  carry  the  roller  back 
to,  and  around,  the  wrist  again  and  so  proceed,  progressing  toward 
the  base  of  the  thumb  (Fig.  37).  Bandage  for  all  the  fingers  and 
thumb,  see  Fig.  38. 


Fig.  40. — Spica  for  shoulder.     Fig.  41. — Bandage     for 
{Heath.)  head.     (Stewart.) 


Fig.  42. — Barton's 

bandage.     {Gould's 

Illust.  Diet.) 


Bandage  for  the  Hand  and  Arm. — Begin  with  circular  turns  around 
the  wrist  and  then  carry  a  "  figure-of-eight "  about  the  wrist  and  hand; 
finish  with  spiral  turns  progressing  up  the  arm  (Fig.  39). 

Spica  for  the  Shoulder. — Begin  on  the  arm  about  the  insertion  of 
the  deltoid  and  make  two  or  three  circular  turns  about  the  arm. 
Next  carry  the  roller  across  the  shoulder,  approaching  the  sound 
axilla  from  behind;  across  under  the  axilla  and  over  the  breast  to 
the  injured  shoulder  and  around  the  arm  again  (Fig.  38). 

Ba7idage  for  the  Neck. — The  shoulder  and  head  must  be  included 
in  the  bandage  for  the  neck  if  it  is  to  be  effective.  Begin  on  the 
shoulder  and  carry  the  roller  through  the  axilla  and  around  the 
neck  once  or  twice.     Take  the  turn  next  about  the  neck  and  beneath 


46 


DRESSINGS,  BANDAGES,    SPLINTS 


Fig.  43-— Capitellum.      {Heath.) 


Fig.  44.— Capitellum  completed.      {Heath.) 


BANDAGE   FOR   THE   EYE 


47 


the  jaw,  behind  the  ear  on  the  sound  side,  over  the  top  of  the  head, 
down  in  front  of  the  ear  on  the  affected  side.  Next  carry  the 
roller  horizontally  around  the  neck  and  then  beneath  the  jaw  once 
more;  again  vertically  around  the  head;  but  this  time  it  passes  in 
front  of  the  ear  on  the  sound  side  and  behind  the  ear  on  the  affected 
side.  Carry  the  roller  now  a  third  time  beneath  the  jaw  and,  finally, 
from  the  occiput  around  the  forehead  to  fix  the  other  turns. 

Bandage  for  the  Head. — -A  dressing  may  be  secured  in  many  in- 
stances by  simple  turns  about  the  forehead  and  occiput;  but  the 


^■ipi 

m 

t     /I 

^^^^Be^  ^-'         ^I^^Hj 

L 

k 

Fig.  45. — Showing  manner  in  which 
eye  is  covered  and  the  ear  engaged  in 
one  slit  in  the  bandage  and  the  occiput 
in  the  other. 


Fig.  46. — Showing  sound  eye  free 
and  manner  of  tying  together  the  two 
ends  of  the  bandage  on  the  sound  side. 


bandage  may  be  made  to  hold  firmer  if,  as  it  approaches  a  certain 
point,  it  is  raised  in  one  turn  and  lowered  in  the  next.  It  has  the 
appearance  of  a  spiral  reverse  (Fig.  41). 

Barton's  bandage  may  be  used  (Fig.  42).  Begin  at  the  top  of 
the  head,  carry  the  roller  beneath  the  chin,  up  to  the  vertex,  across 
and  to  a  point  below  the  occiput.  From  this  point,  carry  it  forward 
to  the  chin  and  on  to  the  occiput.  Bring  it  up  to  the  top  of  the 
head  and  again  beneath  the  chin  and  proceed  as  in  the  beginning. 

Figs.  43  and  44  represent  one  method  of  applying  the  recurrent 
or  capitellum  to  the  head. 

Morley  describes  a  useful  and  practical  bandage  for  the  eye 
(J.  A.  M.  A.,  Mch.  27,  1909).     Take  a  piece  of  muslin,  or  gauze, 


48  DRESSINGS,  BANDAGES,   SPLINTS 

long  enough  to  go  about  the  head  and  wide  enough  to  cover  the 
orbital  region.  At  its  center  cut  a  round  hole  for  the  ear  of  the 
affected  side  and  further  back  an  oblong  slit  for  the  occiput.  Trim 
the  bandage  so  as  to  uncover  the  sound  eye.  Split  the  two  ends 
and  tie  these  tails  tight  enough  to  prevent  slipping  (Figs.  45,  46). 

The  crossed  bandage  for  both  eyes  is  a  figure-of- 
eight  wath  circular  turns  about  the  head  (Fig.  47). 
Bandage  for  a  Stump.  Begin  with  circular 
spiral  turns  some  distance  up  the  limb.  Carry 
the  bandage  back  and  forth  over  the  end  of  the 
stump,  and  finish  by  more  circular  turns. 

SPLINTS 
Fig.  47.— Bandage  for       Xo  immobilize,  to  prevent  muscular  contraction, 

both  eyes.     (Heath.)  ...  t  i  i 

or  to  secure  lunctional  rest,  splmts  play  a  large 
part  in  surgical  practice.  The  emergency  surgeon  must  be  fami- 
liar with  the  principles  regulating  their  employment  and  with  the 
practical  details  of  their  use.  A  splint  must  have  rigidity;  it  should 
be  light.  A  number  of  materials  offer  these  properties  in  varying 
degrees,  though  none  are  ideal  perhaps,  or  universally  applicable — ■ 
wood,  metal,  leather,  wire,  cardboard,  felt,  plaster  of  Paris,  silicate 
of  potash — -each  has  its  special  field  of  usefulness.  More  especially 
employed  in  emergency  practice  are  wood,  metal,  and  plaster. 

Wooden  Splints. — Wood  is  the  material  usually  most  available 
when  temporary  splints  must  be  improvised.  Often  these  splints 
may  be  used  for  permanent  fi.xation,  though  not  so  much  so  perhaps 
as  formerly.  From  soft  wood — a  thin  pine  wood — -the  appropriate 
form  may  be  readily  whittled;  and,  when  applied,  well  wrapped 
so  as  to  conform  to  the  parts,  furnishes  a  fixation  at  once  light  and 
rigid.  The  splint  must  be  wider  than  the  limb  and  long  as  the  part 
to  be  immobilized,  but  not  so  long  as  to  produce  discomfort.  The 
sound  limb  may  be  used  as  a  pattern  in  modeling  the  splint.  Such 
splints  have  the  disadvantage  that  they  are  hard  to  keep  in  place. 
A  number  of  thin  wooden  strips  may  be  glued  to  felt,  or  held  to- 
gether by  adhesive  plaster,  to  form  effective  fixation  in  certain 
fractures  of  the  humerus  and  thigh.     On  this  principle  the  Dutch 


PLASTER   OF   PARIS  49 

cane  splints  are  constructed  for  use  in  the  emergencies  of  warfare. 
Gooch's  splint  is  made  from  a  pine  board  2  feet  long  and  6  or  8  inches 
wide  and  }i  inch  thick,  pasted  on  to  felt  and  then  split  in  strips  H 
inch  wide.  Before  the  ordinary  wooden  splint  is  applied,  it  should 
be  padded  with  absorbent  cotton  2  to  4  inches  thick  and  wrapped 
with  a  gauze  roller.  The  cotton  should  be  distributed  to  corre- 
spond to  the  irregularities  of  the  limb.  The  spHnt  is  molded  to 
the  limb,  and  held  in  place  with  adhesive  strips  while  the  roller 
bandage  is  applied. 

Metal  splints  as  ordinarily  employed  are  scarcely  available  in 
emergency  practice.  These  materials  cannot,  as  a  rule,  be  readily 
worked  into  shape;  but,  on  the  other  hand,  if  ready-made,  are 
likely  not  to  fit.  However,  in  case  of  necessity,  a  splint  could  be 
cut  from  tin  or  from  wire  gauze.  Wire  gauze,  indeed,  forms  part 
of  the  outfit  of  the  military  emergenc}'  bag.  It  can  be  patterned, 
molded  and  bandaged  to  the  part;  the  cut  edges  should  be  turned 
over  or  covered  with  cloth. 

Plaster. — ^Plaster  of  Paris,  on  the  whole,  is  the  material  best 
adapted  to  the  exigencies  of  emergency  practice.  It  is  not  too  bulky, 
cheap,  easily  obtained,  and  readily  prepared;  once  applied,  it  is 
not  unduly  hea\y  and  furnishes  a  firm  support.  It  has  the  special 
advantage  that  it  can  be  molded  to  the  part;  the  disadvantage,  that 
it  may  be  difficult  to  remove  when  applied  as  a  roller  bandage. 
Plaster  is  spoiled  by  exposure.  One  should  buy  a  good  quality  and 
keep  it  dry.  Old  plaster  should  be  baked  before  using.  Plaster 
may  be  applied  on  a  roller  bandage  or  on  strips  to  make  a  molded 
splint.  The  splint  form  is  better  when  the  parts  must  be  frequently 
inspected  or  when  much  sw^elling  is  anticipated.  The  plaster 
roller  may  be  prepared  from  the  ordinary  gauze  roller  or  from  crino- 
line. The  latter  is  perhaps  the  best.  The  rollers  should  be  about 
4  yards  in  length;  2,  3,  and  $H  inches  in  width.  To  prepare  the 
plaster  hajidage,  pour  the  plaster  on  a  table  or  in  a  wide  shallow  basin. 
Start  the  loose  end  of  the  roller  through  the  plaster,  rubbing  it  in 
thoroughly,  and  as  fast  as  it  is  impregnated  have  the  assistant  re- 
roll  it  (Fig.  48).  These  bandages  will  keep  indefinitely  in  an  air- 
tight container.     Prepared  in  this  way  they  are  much  more  satis- 


50 


DRESSINGS,  BANDAGES,   SPLINTS 


factory    than    if    bought    ready-made — and    certainly    much    less 
expensive. 

Method  of  Applying. — -When  the  limb  is  ready,  washed,  and 
covered  with  glazed  cotton  or  stockinet,  the  plaster  roller  is  set  in 
a  pan  of  warm  water  deep  enough  to  cover  it.  When  the  bubbles 
cease  to  rise,  it  is  ready  to  apply.  Seizing  it  at  each  end,  wring  it 
gently.  Begin  by  making  a  few  oblique  turns  at  first  to  secure  the 
dressing  or  cotton,  and  then  cover  the  limb  by  systematic  circular 
turns,  progressing  from  below  upward,  each  turn  overlapping  the 
preceding  one.  The  "reverse"  must  not  be  used.  A  little  loose 
plaster  may  be  spread  on  and  moistened  to  give  a  smooth  and  even 
finish.     The  limb  must  be  supported  and  the  extension  maintained 


Fig.  48. — Method  of  rolling  plaster  bandage. 

until  the  plaster  has  hardened.  A  Httle  salt  added  to  the  water 
hastens  the  process.  If  there  is  danger  of  swelling,  or  if  the  limb 
cannot  be  frequently  inspected,  it  is  better  to  split  the  case  before 
leaving  the  patient.  Sometimes  it  is  quite  a  task  to  split  a  plaster 
cast  after  it  is  thoroughly  hardened.  The  labor  may  be  greatly 
lessened  by  the  use  of  simple  syrup,  a  groove  being  first  cut  with 
plaster  knife  or  saw;  if  the  groove  is  kept  filled  with  syrup  while 
the  cutting  is  in  progress,  one  will  get  through  the  plaster  rapidly. 

Plaster  splints  are  made  by  cutting  several  thicknesses  of  crino- 
line, appropriate  to  the  shape  of  the  limb.  It  is  saturated  with 
plaster,  each  layer  separately,  dipped  in  warm  water  until  well 
soaked,  then  apphed  and  molded  to  the  limb.  Fix  it  with  circular 
turns  of  a  musUn  bandage.  The  second  splint,  if  needed,  is  then 
applied  and  fixed  by  a  second  series  of  circular  turns.     The  splints 


PLASTER   OF   PARIS   SPLINTS  5 1 

may  be  fixed  by  a  plaster  roller  if  desired.  A  still  better  way  is  to 
fold  the  crinoline  into  the  desired  number  of  layers  and  cut  them 
all  at  once  from  the  pattern  determined.  Warm  water  and  a  basin 
are  next  provided  and  plaster  is  slowly  sifted  into  the  water,  until 
it  ceases  to  bubble;  when  it  is  mixed,  until  it  has  the  consistency  of 
cream.  The  cloth  is  then  dipped  in  and  saturated.  When  well 
soaked,  the  excess  of  plaster  is  pressed  out  and  the  splint  is  ready  to 
apply. 

The  Bavarian  plaster  splint  is  particularly  useful  in  immobilizing 
the  leg.  Cut  two  pieces  of  flannel  long  enough  to  extend  from  the 
upper  end  of  the  thigh  under  the  heel  to  the  ball  of  the  toes,  a  few 
inches  wnder  than  the  greatest  girth  of  the  limb.  Stitch  these 
pieces  together  along  the  middle  line  for  the  length  of  the  leg.  Put 
the  splint  thus  formed  under  the  limb,  with  the  seam  exactly  in  the 
middle;  bring  the  inner  half  around,  fitting  it  to  the  leg,  the  dorsum 
and  sole  of  the  foot,  like  a  stocking.  Smear  this  stocking  wdth 
liquid  plaster  and,  before  it  sets,  turn  the  outer  half  over  the  plaster 
and  mold  it  and  adjust  the  end  pieces  to  the  sole.  The  splint  can 
be  easily  removed,  as  the  seam  along  the  back  acts  as  a  perfect 
hinge. 


CHAPTER  VII 

SHOCK 

Shock  is  a  constitutional  state  characterized  by  lowered  blood  pres- 
sure, due  to  vaso-motor  paralysis. 

In  practice,  the  term  '^ shock"  includes  the  complex  of  symptoms 
arising  from  the  vaso-motor  paralysis,  hemorrhage,  mechanical  in- 
terferences with  circulation  and  respiration,  and  beginning  infection. 

It  may  not  be  possible  to  analyze  the  symptoms,  determining  the 
part  played  by  each  of  these  various  conditions  in  a  given  case,  nor 
is  it  necessary  to  do  so. 

Nevertheless,  the  proper  understanding  of  shock  as  a  separate 
entity  is  essential  in  emergency  surgery  next  to  skill  in  hemostasis. 

Peripheral  impulses  reach  the  automatic  centers  controlling  blood 
pressure  and  overwhelm  them.  Such  is  the  commonly  accepted 
view  of  shock  production. 

Lucy  Waite,  after  reviewing  the  subject  from  every  standpoint, 
concludes  that,  according  to  our  present  light,  we  must  consider  it 
primarily  a  disturbance  of  the  great  sympathetic  nervous  system; 
secondarily,  the  vascular  system,  resulting  in  vaso-motor  paresis 
and  dilatation  of  the  right  side  of  the  heart  and  the  large  vessels; 
in  natural  sequence  derangement  of  the  solar  plexus  and  the  auto- 
matic visceral  gangUa  follows;  finally  there  is  suppression  of  visceral 
activity — of  rhythm,  absorption,  and  secretion.  (Medical  Record, 
Sept.  8,  1906.) 

This  is  practically  in  accord  with  the  results  of  recent  experi- 
ments of  Janeway  and  Ewing.  ''The  loss  of  vaso-motor  control 
is  never  due  to  ocopnia  or  central  nervous  exhaustion  in  their 
opinion  but  is  rather  a  matter  of  inhibition.  (Annals  Surgery, 
Feb.,  1914.) 

The  symptoms  of  shock  vary  in  degree  with  its  severity  and  are 
chiefly  incident  to  the  lowered  blood  pressure :  thirst,  pallor,  subnor- 

52 


DIAGNOSIS    OF    SHOCK  53 

mal  temperature,  shallow  Ijreathing,  frequent  sighing  or  yawning, 
rapid  pulse,  relaxed  sphincters,  faintness,  nausea  or  vomiting,  and 
unconsciousness. 

These  may  appear  in  their  slightest  manifestations,  or  in  such 
forms  as  usher  in  death.  As  Waite  says,  syncope  causing  always  a 
cerebral  anemia  is  practically  identical  with  the  last  manifestations 
of  overwhelming  shock. 

Whether  shock  will  be  mild,  severe,  or  fatal  depends  upon  the 
state  of  the  individual,  the  character  and  continuance  of  trauma, 
the  means  of  injury,  and  the  tissues  wounded.  Age,  sex,  general 
health,  and  mental  state  are  factors  to  be  taken  into  consideration. 

Crushing  injuries  with  mangled  nerves  sending  their  constant  sig- 
nals to  the  disturbed  vaso-motor  centers  furnish  conditions  favorable 
to  fatal  shock.  Railroad  accidents  are  typical  of  such  as  produce 
the  severest  symptoms  of  shock,  for  fright  and  violent  emotions 
even  without  injury  may  be  followed  by  vaso-motor  paralysis. 

Certain  tissues  resent  insult  more  than  others.  Those  which  line 
the  body  cavities  are  most  sensitive  with  respect  to  injury;  the 
peritoneum,  the  pleura,  the  dura,  and  the  synovial  membranes 
of  the  large  joints.  This  is  true  whether  the  trauma  be  accidental 
or  operative. 

The  diagnosis  of  shock  as  distinct  from  hemorrhage  and  collapse 
cannot  always  be  made  with  certainty.  As  Waite  says,  the  diag- 
nosis of  shock  is  simply  the  recognition  of  the  clinical  phenomena, 
for  we  have  no  chemical  or  pathological  findings  to  aid  us. 

In  many  instances  it  may  be  differentiated  from  collapse  by  the 
history  of  the  case. 

In  collapse  the  heart  action  is  slow  and  feeble,  whereas  in  shock 
it  is  rapid  and  feeble. 

In  hemorrhage  the  symptoms  may  be  rapidly  progressive,  but  in 
uncomplicated  shock  the  symptoms  are  stationary  or  improve. 
Observe,  therefore,  the  action  of  the  pulse  and  the  movement  of 
the  temperature.  In  hemorrhage  the  temperature  falls  and  the 
pulse  rate  increases.  In  shock  the  pulse  becomes  gradually  slower; 
the  temperature  gradually  rises. 

The  prognosis  in  the  severe  cases  will  be  for  a  little  time  decidedly 
uncertain.     The  sufferer  from  traumatic  shock  may  give  the  doctor 


54 


SHOCK 


an  erroneous  notion  of  the  gravity  of  the  case,  unless  the  condition 
of  the  pulse  is  carefully  noted;  for  he  may  complain  of  no  pain,  is 
cheerful  in  the  face  of  his  calamity,  discusses  the  need  of  operative 
measures  quite  coolly  and  directs  the  management  of  his  case  generally. 
He  seems  quite  rational,  and  yet  it  often  happens  that  after  recovery 
he  has  no  recollection  of  what  he  said  or  did  or  felt.  It  is  prob- 
able, in  the  presence  of  grave  injury  that,  if  the  pulse  is  thready  and 
still  failing,  the  patient  does  not  know  what  he  is  talking  about,  how- 
ever lucid  his  expression  may  appear.  A  little  later  he  may  be  in 
active  delirium.  Any  increase,  not  too  lon^  delayed,  in  the  blood 
pressure  and  the  attendant  improvement,  is  a  cause  for  hope.  It 
may  take  many  hours  before  the  reaction  is  complete. 

Any  aggravation  of  the  symptoms  after  reaction  is  once  under  way 
never  indicates  a  return  of  the  shock,  hut  points  to  hemorrhage  or 
infection. 

It  is  true  that,  as  a  rule,  when  once  improvement  begins  the  out- 
look is  favorable,  but  the  prognosis  must  always  be  guarded  in  the 
case  of  the  elderly. 

An  old  flagman  was  brought  to  the  City  Hospital  with  both  limbs 
crushed  off,  having  fallen  under  a  passing  engine.  He  was  in  full 
shock  and  had  lost  some  blood  from  a  scalp  wound.  He  was  almost 
pulseless  and  yet  his  mind  seemed  clear.  His  condition  precluded 
operation.  The  mangled  tissues  were  trimmed  and  carefully 
cleansed  and  wrapped  in  moist  antiseptic  compress  until  such  time 
as  formal  amputation  might  be  undertaken.  Under  the  treatment 
for  shock  he  gradually  improved.  His  circulation  and  respiration 
grew  stronger,  but  not  sufficiently  so  as  to  favor  operation.  At  the 
end  of  twenty-four  hours  he  began  all  at  once  to  grow  weaker,  fell 
into  a  stupor,  and  in  a  few  hours  died.  If  the  amputation  had  been 
undertaken,  he  would  have  died  on  the  table,  and  thus  another  fa- 
tality would  have  been  charged  to  active  intervention. 

The  treatment  of  shock  has  been  the  subject  of  much  discussion  in 
recent  years.  The  most  diverse  opinions  exist  and  the  most  diverse 
methods  have  been  proposed,  but  we  have  learned  from  the  ex- 
perience of  Crile  and  others  that  it  is  as  important  to  know  what  not 
to  do  as  what  to  do. 

The  whole  list  of  cardiac  and  spinal  stimulants  so  commonly  in- 


TREATMENT   OF   SHOCK 


55 


jected  hastily,  indiscriminately  and  collectively,  are  shown  to  be 
not  only  useless,  but  distinctly  harmful.  The  patient  doubtless 
often  recovers  not  on  account  of,  but  in  spite,  of,  such  treatment. 

In  ordinary  cases,  these  directions  are  sufficient  to  be  borne  in 
mind:  disturb  the  patient  as  little  as  possible;  lower  the  head;  keep 
the  body  warm;  attempt  no  operative  measures  until  the  symptoms 
are  improved,  unless  it  be  to  check  hemorrhage,  or  to  amputate  in 
certain  crushing  injuries. 

Adrenalin  chloride  is  the  most  generally  useful  remedy  to  raise 
blood  pressure  in  shock  pure  and  simple,  and  given  hypodermically 
or  intravenously,  it  very  seldom  completely  fails. 

Crile  w^as  enabled  by  means  of  intravenous  infusion  of  adrenalin 
and  salt  solution,  combined  with  artificial  respiration  and  thoracic 
pressure,  to  arouse  a  human  heart  after  it  had  ceased  to  beat  for  nine 
minutes,  and  its  action  was  thus  sustained  for  one-half  hour. 

It  must  be  given  in  small  doses,  frequently  repeated.  The  effects 
are  powerful,  but  fleeting. 

Hypodermically,  give  5  to  15  minims  of  the  i-iooo  adrenalin  solu- 
tion and  repeat  every  twenty  or  thirty  minutes. 

Intravenous  infusion  is  even  more  satisfactory  and  certain. 
Give  continuous  infusion  of  adrenalin  salt  solution  until  there  are 
signs  of  reaction.  One  teaspoonful  of  i-iooo  adrenalin  added  to 
one  quart  of  normal  salt  solution  is  of  sufficient  strength. 

Xormal  salt  solution  alone  is  effective  within  certain  limits,  but 
finds  its  greatest  field  of  usefulness  in  shock  coexistent  with  hemor- 
rhage. In  shock  uncomplicated  by  extensive  loss  of  blood,  the  saline 
solution  must  be  used  sparingly,  perhaps  better  by  enema  or  hypo- 
dermoclysis;  used  in  large  quantities  intravenously,  it  may  eventually 
defeat  the  end  for  which  it  is  employed  by  acting  as  a  mechanical 
obstruction  to  respiration.  For  it  must  be  remembered  that  under 
such  circumstances  it  finds  its  way  into  the  thoracic  and  abdominal 
tissues  and  interferes  with  the  movements  of  the  diaphragm  and 
ribs  by  its  mere  presence.  According  to  Crile,  320  c.c.  per  kilo  of 
body  weight  led  to  such  accumulation  of  fluid  in  the  splanchnic  area 
as  to  embarrass  respiration. 

Do  not  give,  then,  more  than  a  pint  of  normal  salt  solution  in- 
jected slowly,  in  uncomplicated  shock.     (For  technic  of  intravenous 


56  SHOCK 

infusion,  see  page  59).  Murphy  uses  sodium  bicarbonate  i  dram 
to  1 3^  pints  of  hot  water  as  a  proctoclysis,  repeating  the  dose  every 
three  to  five  hours. 

Crile's  pneumatic  suit  seems  to  be  entirely  trustworthy  as  a  means 
of  raising  blood  pressure;  but,  of  course,  cannot  be  used  in  the 
shock  occurring  in  emergency  practice. 

The  prevention  of  shock  is  always  something  to  be  considered  in 
operative  work.  Morphine,  3^  grain  hypodermically,  before  the 
anesthesia,  is  a  real  aid.  ''Blocking"  the  nerves  by  cocaine  in- 
jections above  the  site  of  operation  is  likewise  advantageous  and  is 
recommended  by  Gushing  and  Crile.  The  nerve  may  be  exposed 
in  its  course  under  local  anesthesia  and  in  turn  injected. 

In  abdominal  work  the  viscera  must  he  handled  with  care;  for,  as 
Byron  Robinson  has  shown,  shock  from  this  source  is  directly  pro- 
portionate to  the  amount  of  manipulation  or  traction  upon  the 
viscera. 


CHAPTER  VIII 
HEMORRHAGE 

Definitions. — i.  Arterial  hemorrhage  is  due  to  wounds  of  arteries 
and  is  characterized  by  spurting  and  the  bright  red  color. 

2.  Venous  hemorrhage  is  due  to  wounds  of  the  veins  and  is  char- 
acterized by  dark  color  and  steady  flow. 

3.  Capillary  hemorrhage  is  characterized  by  persistent  oozing 
and  spontaneous  arrest. 

4.  Parenchymatous  hemorrhage  is  due  to  wounds  of  those  organs 
and  tissues  in  which  the  small  arteries  terminate  directly  in  veins; 
no  capillaries  intervening,  as  in  the  erectile  tissues. 

5.  Primary  hemorrhage  occurs  immediately  after  the  injury. 

6.  Intermediate  or  reactionary  hemorrhage  occurs  within  twenty- 
four  hours  and  is  due  to  the  release  of  clots  or  the  slipping  of  the 
ligature. 

7.  Secondary  hemorrhage  occurs  after  twenty-four  hours,  before 
the  cicatrization  of  the  wound,  and  is  usually  due  to  sloughing  or 
suppuration  or  the  too  rapid  absorption  of  the  catgut  ligature. 

8.  Internal  or  concealed  hemorrhage  occurs  when  the  blood  is 
emptied  into  one  of  the  large  cavities;  abdomen,  thorax  or  cranium. 

CONSTITUTIONAL    EFFECTS    OF   HEMORRHAGE 

The  constitutional  effects  of  hemorrhage  vary  with  the  amount 
and  the  rapidity  of  the  loss  of  blood.  Thus  a  comparatively  small 
amount  of  blood  poured  out  rapidly  will  produce  more  marked 
symptoms  than  a  much  larger  amount  drained  away  slowly. 

The  constant  accompaniments  of  severe  hemorrhage  are  pallor, 
dizziness  and  faintness,  rapid  and  weak  pulse,  subnormal  tem- 
perature, rapid  and  irregular  breathing,  frequent  yawning  or  sigh- 
ing, nausea,  and  vomiting. 

57 


58  HEMORRHAGE 

Fatal  hemorrhage,  or  one  likely  to  be  so,  is  indicated  by  livid  lips, 
blue  finger  nails,  dilated  nostrils,  pallid  mucous  membranes,  dyspnea, 
ringing  in  the  ears,  syncope,  collapse  and  unconsciousness. 

Subsequent  to  the  arrest  of  a  dangerous  hemorrhage,  occur  rapid  and 
irregular  pulse,  rise  of  temperature,  asthenia,  a  disturbed  mental 
condition,  usually  muttering  delirium.  This  is  hemorrhagic  fever. 
As  the  general  condition  improves,  the  mind  gradually  clears  up. 
The  lowered  vitality  following  the  hemorrhage  favors  the  develop- 
ment of  various  inflammatory  processes,  and  one  must  carefully 
watch  for  the  onset  of  these. 

The  diagnosis  of  hemorrhage  is  not  difficult  except  in  the  case  of 
internal  hemorrhage,  or  when  shock  is  present. 

In  the  case  of  bleeding  into  the  cranial  cavity,  various  forms  of 
paralysis  and  nervous  disturbances,  together  with  the  general 
symptoms,  will  form  the  basis  of  the  diagnosis. 

In  the  case  of  bleeding  into  the  thorax  and  abdomen,  the  symp- 
toms, the  physical  signs,  and  the  history  of  the  case  will  point  to  the 
condition.     (See  Injuries  to  Thorax  and  Abdomen.) 

WTien  shock  is  also  present  it  may  be  almost  impossible  to  tell  how 
much  of  the  symptoms  are  due  to  the  one  or  the  other,  for  the  symp- 
toms of  shock  and  hemorrhage  are  practically  identical. 

It  is  useful  to  remember  that  the  symptoms  produced  by  shock  are 
usually  immediate  and  tend  to  improve,  except  in  the  fatal  cases. 
On  the  other  hand,  the  symptoms  of  unchecked  hemorrhage  tend 
to  grow  worse. 

TREATMENT    OF   HEMORRHAGE 

The  First  Indication  is  the  Arrest  of  Hemorrhage.  Constitutional 
measures  are  then  applied  with  a  view  to  supporting  the  heart's 
action.  In  moderately  severe  cases  give  32  ounce  of  whiskey  or  a 
hypodermic  of  strychnine  (3^o  to  Ho  grain),  or  of  adrenalin  chloride, 
and  repeat  every  hour  until  the  symptoms  have  improved.  Apply 
warm  blankets,  hot  water  bottles,  or  hot  irons  well  wrapped.  Do 
not  burn  the  patient.  Keep  him  quiet,  with  head  lowered.  Attend 
to  the  ventilation.  As  soon  as  possible  give  warm  drinks  and  a 
nutritious  but  easily  digested  diet.  Do  not  overstimulate,  as  the 
reaction  in  that  case  will  be  unduly  severe. 


INTRAVENOUS   INFUSION  59 

In  the  dangerous  cases  of  hemorrhage,  in  addition  to  these  meas- 
ures, do  not  fail  to  employ  normal  salt  solution  either  by  enema, 
subcutaneous  injection,  or  intravenous  infusion. 

In  the  gravest  cases,  enemas  will  be  of  no  avail,  for  absorption  has 
practically  ceased. 

Hypodermoclysis  will  be  a  little  better.     For  this  purpose  employ: 

I^ — Sodii  chloridi.,  ■  5    i. 

Sodii  bicarb.,  gr.  xv. 

Aq.  destill.,  §    xvi. 

The  necessary  apparatus:  a  carefully  disinfected  fountain  syringe 
or  a  funnel  with  rubber  tubing,  a  large  needle  (an  aspirating  needle). 
One-half  pint  or  more  of  the  solution  is  injected  by  this  means 
under  the  skin  over  the  abdomen  or  breasts. 

Intravenous  Infusion. — In  the  gravest  cases,  the  same  solution 
by  the  same  means  may  be  injected  into  the  venous  circulation. 
Select  a  vein  at  the  elbow,  employ  the  strictest  asepsis,  and  expose 
the  vein  by  incision.  Loosen  it  from  adjacent  tissues  by  careful 
blunt  dissection  and  slip  three  catgut  ligatures  under  it.  Introduce 
the  needle,  or  else  the  vein  may  be  opened  and  a  cannula  used.  The 
cannula  or  needle  is  to  be  held  in  place  by  tying  the  middle  ligature. 
Slowly  inject  a  pint  or  more  of  the  solution,  the  temperature  of  which 
should  be  105  to  115.  Withdraw  the  cannula,  remove  the  middle 
ligature,  and  tie  the  two  remaining.  Close  the  wound  and  dress 
aseptically.  Keep  the  funnel  full  during  the  injection,  so  that  no 
air  may  be  carried  into  the  vein. 

Crile  recommends  direct  transfusion  from  the  vein  of  a  well  person 
into  that  of  the  patient,  but  of  course  this  method  is  scarcely  available 
in  emergencies  of  general  practice. 

Parke-Davis  &  Company  market  a  sterile  salt  in  sterile  tubes 
which  needs  only  to  be  emptied  into  a  liter  of  sterile  water  to  form  a 
solution  for  instant  use.     The  formula  used  is  as  follows: 

Calcium  chloride,  0.25  gm. 

Potassium  chloride,  0,1    gm. 

Sodium  chloride,  9.0    gm. 

Remember  that  intravenous  infusion  is  not  to  be  employed  until 
the  hemorrhage  is  arrested. 


6o  HEMORRHAGE 

HEMOSTASIS — ARREST    OF   HEMORRHAGE;    GENERAL   PRINCIPLES 

Spontaneous  arrest  of  hemorrhage  is  due  to  several  factors:  con- 
traction and  retraction  of  the  injured  vessels,  diminishing  blood 
pressure  due  to  weakening  heart  action,  formation  of  a  clot,  these  are 
the  agents  which  nature  employs. 

Capillary  hemorrhage  tends  to  spontaneous  arrest,  likewise  the 
arterial  hemorrha.ge  of  lacerated  wounds. 

Hetywstatic  measures  locally  applied  are  chemical,  thermal,  and 
7nechanicaL 

(A)  Chemical  remedies,  chiefly  st}-ptics,  are  now  very  rarely  em- 
ployed. Such  as  are  used  are  expected  to  favor  the  formation  of 
a  clot  without  doing  violence  to  the  tissues.  In  a  persistent  capillary 
hemorrhage,  dioxide  of  hydrogen  or  acetanilid  is  often  useful  and 
harmless,  but  the  most  useful  remedy  locally  applied  is  adrenalin 
chloride.     The  i-iooo  solution  is  commonly  used. 

fB)  Thermal  hemostasis  is  that  induced  by  heat.  Hot  water  or 
hot  normal  salt  solution  alone  will  usually  arrest  a  moderate  bleed- 
ing. Use  the  solution  as  hot  as  can  be  borne  by  the  hand.  Hot 
solutions  are  especially  useful  since  they  serve  the  double  purpose  of 
antisepsis  and  hemostasis.  The  actual  cautery  may  be  necessary 
in  spongy  tissue  where  the  oozing  is  persistent  but  ill  defined.  The 
iron  should  not  be  hotter  than  a  dull  red  and  must  be  held  in  contact 
for  some  moments.  Cold  may  be  used  but  is  much  more  likely  to 
lower  cellular  vitality. 

(Cj  Mechanical  hemostasis  includes  (i)  direct  pressure,  (2)  com- 
pression, (3)  acupressure,  (4)  forcipressure,  (5)  torsion,  (6)  ligation. 

(i)  Direct  pressure  is  of  large  service  especially  in  "first  aid" 
treatment.  The  finger  or  thumb  is  pressed  directly  into  the  wound, 
or  on  each  edge  of  the  wound.  If  the  pressure  is  to  be  prolonged, 
the  finger  will  tire  and  a  plug  or  tamponade  of  gauze  must  be  sub- 
stituted. Gauze  wrung  out  of  a  sterile  solution  is  packed  into  the 
wound. 

Direct  pressure  is  sufficient  in  the  slight  hemorrhage  of  operative 
wounds.  The  assistant  presses  a  gauze  compress  on  the  bleeding 
surface,  withdraws  it  by  a  gliding  movement,  and  the  bleeding 
practically  ceases. 


IIEMOSTASIS  6 1 

In  general,  the  larger  the  vessels,  the  firmer  and  more  prolonged 
must  be  the  pressure. 

In  severe  hemorrhage,  direct  pressure,  is  of  course,  a  mere  tem- 
porary expedient. 

Parenchymatous  bleeding  is  checked  by  direct  pressure.  The 
wound  of  the  organ  is  lined  with  a  layer  of  gauze.  In  this  gauze 
cavity,  complete  the  tamponade.  This  compress  should  be  with- 
drawn within  twenty-four  to  forty-eight  hours.  It  may  be  painful 
to  pull  out.  Release  a  little  at  a  time,  or  soften  the  adhesions  with 
peroxide. 

2.  Compression  aims  to  occlude  the  vessel  above  or  below  the 
wound.  In  the  emergency,  a  finger  is  applied  to  an  artery  at  some 
convenient  point  along  its  course  at  some  distance  above  the 
wound.  Pressure  is  most  effective  if  the  vessel  lies  closely  over  bone. 
Large  veins  are  similarly  compressed  below  the  wound. 

In  the  case  of  wounds  of  the  extremities,  the  main  vessels,  in- 
cluding both  the  vein  and  artery  or  either  alone,  may  be  compressed 
by  the  tourniquet.  The  pressure  is  made  firmest  over  the  vessel  by 
laying  over  its  course  a  body  such  as  a  small  roller  bandage,  before 
the  constricting  band  is  applied  above  the  wound  (Figs.  53,  54). 

The  simplest  and  most  convenient  tourniquet  is  a  rubber  band  or 
tube.  After  being  tightened,  the  crossed  ends  are  caught  and  held 
in  place  by  an  artery  forceps.  It  must  always  be  remembered  that 
the  tourniquet  is  likely  to  cut  off  all  the  blood  supply  to  the  ex- 
tremity and  if  too  long  applied  will  produce  gangrene.  Paralysis 
may  foUow  from  pressure  on  the  nerves.  Wrap  the  arm  with  a  towel 
and  apply  the  tourniquet  over  that. 

Capillary  oozing  is  frequently  troublesome  after  the  constriction 
is  removed.     Constrictionis  objectionable  on  that  account. 

3.  Acupressure  is  now  seldom  used  and  yet,  under  certain  circum- 
stances, may  render  great  aid.  The  artery  may  be  deep  and  retracted 
or  imbedded  in  scar  tissue  or  aponeurosis  and  cannot  be  seized  by  the 
forceps.  In  such  a  case  a  needle  passed  under  the  artery  and  secured 
with  a  figure-of-eight  Hgature  wound  around  its  protruding  ends  will 
press  the  artery  between  it  and  the  tissues  and  stop  the  flow  (Fig.  49). 

4.  Forcipressure,  the  control  of  hemorrhage  by  seizing  the  ends 
of  the  bleeding  vessels  with  forceps,  is  the  expedient  most   com- 


62 


HEMORRHAGE 


monly  employed  in  operative  wounds.  In  the  accidental  wounds 
of  large  arteries,  it  affords  immediate  control  of  the  hemorrhage. 
For  the  small  vessels  such  pressure  is  sufficient,  the  forceps  remain- 
ing attached  for  a  certain  length  of  time.  The  end  of  the  vessel 
should  be  seized  with  as  little  other  tissue  as  possible.  If  it  is  a 
large  vessel  it  may  be  cleared  by  a  moment's  dissection. 

5.  Torsion  is  added  to  forcipressure,  if  that  is  not  sufficient  (Fig. 
50).  Before  removing  the  forceps,  it  is  given  two  or  three  turns  on 
its  long  axis.  The  inner  coats  of  the  artery  are  ruptured  and  con- 
tracted, producing  the  same  conditions  favorable  to  hemostasis  as 
are  found  in  the  artery  in  lacerated  w^ounds.  If  the  artery  is  a  little 
larger,  it  is  drawn  for  yi.  i^ch  out  of  its  sheath,  a  second  forceps  grasps 


Pig.  49. — Acupressure.     (Moullin.) 

it  higher  up  and  is  held  stationary,  while  the  lower  one  twists  the 
intervening  segment,  the  purpose  being  to  avoid  injury  to  the  sheath 
and  the  vasovasorum. 

In  making  torsion,  do  not  pull  at  the  same  time,  for  fear  of  tearing 
the  other  tissues  instead  of  twisting  the  artery.  Torsion  must  not  be 
used  where  the  tissues  are  loose  or  cellular. 

Torsion  is  of  advantage  especially  in  plastic  surgery,  for  it  leaves 
no  ligature  behind  to  interfere  with  repair;  but  it  is  not  so  certain 
as  ligation. 

6.  Ligation  is  finally  necessary  in  bleeding  from  the  larger  vessels. 
Employ  catgut,  chromicized  or  plain.  For  the  largest  vessels  silk  is 
occasionally  used. 

Lift  the  attached  forceps  so  as  to  create  a  pedicle  around  which 
pass  the  thread  and  tie  the  first  knot  (Fig.  51). 

In  tying  the  second  knot,  two  things  are  kept  in  mind;  to  tie 


HEMOSTASIS 


63 


tight  enough  that  the  thread  will  hold  when  the  forceps  is  removed, 
and  not  to  include  the  tip  of  the  forceps  in  the  ligature.  The 
forceps  is  usually  removed  as  soon  as  the  first  knot  is  tied,  so  that 
one  may  be  assured  the  suture  is  not  badly  placed  before  completing 
the  knots.  The  first  knot  is  secured  by  a  second  if  silk  is  used,  and 
by  a  third  if  catgut  is  used.  The  threads  are  then  cut  short,  silk 
I  mm.  and  catgut  2  or  3  mm.  Catgut  is  the  preferable  ligature 
and  a  No.  2  is  amply  strong  for  an  artery  the  size  of  the  radial. 

Ligation  en  masse  may  be  employed  in  parenchymatous  hemor- 
rhage, capillary  oozing,  or  bleeding  from  a  deep  wound.  A  catgut 
suture  is  carried  around  the  bleeding  area  by  a  well  curved  needle, 


Fig.  so. — Torsion.     (Veau.) 


Fig.  si. — Showing  method  of  tight- 
ening  the   ligature.     {Veau.) 


and  all  the  tissues  so  included  are  tied;  or,  in  the  case  of  paren- 
chymatous bleeding  from  a  surface,  a  catgut  suture  may  be  carried 
around  the  area  and  subsequently  tightened  after  the  manner  of 
the  purse  string. 

HEMOSTASIS    IN   SPECIAL   FORMS    OF   HEMORRHAGE 


(a)  Capillary — pressure,    hot    water,    ice,    adrenalin,    peroxide, 
acetanilid,  alum,  ligation  en  masse. 

(b)  Venous — pressure,    compression,   forcipressure,   ligation,   re- 
moval of  all  obstruction  to  venous  flow  above  the  wound. 

(c)  Arterial — pressure,  compression,  forcipressure,  torsion,  ligation 


64  HEMORRHAGE 

(d)  Parenchymatous — pressure  (tamponade),  heat,  ligation  en 
masse. 

(e)  Intermediate  hemorrhage — reopen  the  wound,  turn  out  the  clots 
and  treat  hemorrhage  as  if  it  were  a  primary  one. 

(f)  Secondary  hemorrhage — reopen  the  wound,  turn  out  clots,  and 
apply  compresses.  If  possible  catch  the  ends  of  the  bleeding  vessels. 
If  the  hemorrhage  is  alarming  and  it  is  impossible  to  control  it  by 
compresses  or  forcipressure,  apply  the  tourniquet,  in  the  case  of  an 
extremity,  and  ligate  the  artery  in  its  continuity  above  the  wound. 
If  this  fails  and  the  artery  cannot  be  tied  higher  up,  amputate. 


Fig.  52. 

(g)  Operative  hemorrhage — In  spite  of  artery  forceps,  the  bleeding 
remains  to  the  inexperienced  one  of  the  bugbears  of  operative  work. 
In  many  operations  it  is  the  chief  drawback  to  rapid  work;  more 
time  is  lost  in  catching  and  tying  bleeding  points  than  in  doing  the 
actual  operation.  Oftentimes  the  field  is  masked  by  a  general 
oozing,  and  the  procedure  must  halt  until  the  wound  can  be  packed 
with  hot  compresses,  which  will  usually  be  all  that  is  necessary. 
Gentle  and  momentary  pressure  with  a  gauze  compress  is  usually 
all  that  is  necessary  in  capillary  bleeding. 

In  operations  in  the  various  cavities,  as  the  nose,  mouth,  rectum, 
in  the  mastoid  operation,  etc.,  the  hemorrhage,  even  if  not  discon- 
certing, is  often  very  troublesome  and  some  special  measures  are 
required.  Under  the  circumstances,  Parke  Davis'  adrenalin  gauze, 
which  is  cut  in  narrow  strips,  may  be  packed  in  the  cavity  for  a 
moment  and  on  its  removal  the  operation  may  proceed  (Fig.  52). 


EMERGENCY   HEMOSTASIS  65 

FIRST  AID  IN  DANGEROUS  HEMORRHAGE^ 

It  is  rare  that  the  regulated  measures  for  hemotasis  can  be  applied 
first  hand  in  a  dangerous  hemorrhage.  There  are  certain  temporary 
and  makeshift  but  extremely  useful  procedures  which  the  surgeon 
should  keep  in  mind,  if  for  no  other  reason  than  that  he  may  give 
precise  and  definite  instruction  to  the  layman  who  may  have  to 
play  the  part  of  surgeon  for  the  time  being. 

Intelligent  first  aid  is  the  chief  factor  in  saving  life  in  most  cases 
of  dangerous  hemorrhage  both  in  military  and  civil  practice.  Who- 
ever has  to  meet  these  emergencies  must  keep  cool.  He  must  re- 
member how  to  apply  three  principles  of  treatment,  position,  direct 
pressure,  compression. 

1.  Position. — In  case  the  upper  extremity  is  wounded:  hold  the 
arm  above  the  head.  If  it  is  the  lower  extremity:  put  the  patient 
on  his  back  and  elevate  the  limb.  If  it  is  the  face  or  scalp:  place 
the  patient  in  a  sitting  position. 

2.  Direct  Pressure. — The  wound  is  small,  the  bleeding  is  dangerous : 
plug  the  wound  directly  with  the  thumb  or  finger,  or  press  firmly  on 
each  edge  of  the  wound;  or,  in  any  case  and  better  still,  if  supplied 
with  a  first  aid  packet,  stuff  the  wound  tightly  with  gauze  and 
bandage  firmly.  It  should  be  emphasized  that  a  finger  must  never 
be  thrust  into  a  wound  except  in  cases  of  greatest  urgency  and 
where  other  means  less  likely  to  cause  sepsis  are  not  at  hand. 

3.  Compression. — The  bleeding  vessel  is  recognized  and  its  course 
is  familiar:  compress  it  wdth  the  fingers  at  some  convenient  point 
or,  in  the  case  of  the  extremities,  by  constricting  the  limb. 

In  lieu  of  the  tourniquet,  knot  a  handkerchief,  apply  the  knot 
over  the  artery  and  tie  the  handkerchief  tightly  around  the  limb. 
If  it  is  not  tight  enough,  a  stick  may  be  slipped  under  the  hand- 
kerchief and  given  a  few  turns,  end  for  end.  A  suspender,  a  rope, 
or  a  wire  may,  if  necessary,  be  similarly  employed.  It  must  be  re- 
membered that,  on  the  whole,  circular  constriction  is  not  without  its 
dangers,  and  it  must  not  be  recommended  without  reserve  to  the 
layman. 

^  See  also  "First  Aid  on  Batdefield,"  page  179. 
5 


66  HEMORRHAGE 

The  principal  arteries  near  the  surface  have  each  certain  points 
where  compression  is  most  effective. 

The  temporal  and  occipital  furnish  most  of  the  dangerous  bleed- 
ing in  scalp  wounds. 

The  temporal  may  be  compressed  just  in  front  of  the  upper  part 
of  the  ear. 

The  occipital  may  be  compressed  in  its  course  from  the  tip  of  the 
mastoid  upward  toward  the  occipital  protuberance. 

The  entire  blood  supply  of  the  scalp  may  be  shut  off  temporarily 
by  a  bandage  encircling  the  head,  passing  from  the  forehead,  above 
the  ear,  to  the  base  of  the  skull  and  thence  upward,  just  above  the 
other  ear,  to  the  forehead  again. 

The  facial  is  compressible  as  it  crosses  the  body  of  the  jaw  just 
in  front  of  the  masseter  muscle. 

The  coronary  arteries,  supplying  the  lips,  are  compressed  by  seiz- 
ing the  lip  between  the  forefinger  and  thumb. 

The  carotids  are  controlled  by  compression  of  the  common  carotid 
over  the  transverse  process  of  the  sixth  cervical  vertebra. 

Wounds  of  the  vessels  of  the  neck,  how^ever,  are  of  such  extreme 
danger,  including,  as  a  rule,  both  arteries  and  veins,  that  bleeding 
should  be  controlled  by  direct  pressure  in  the  wound.  Nothing 
can  be  so  well  trusted  here  as  the  finger. 

The  subclavian  is  compressible  against  the  first  rib  behind  the 
middle  of  the  clavicle.  The  shoulder  is  slightly  raised  to  relax  the 
cervical  fascia  and  the  finger  or  a  padded  stick  pushed  directly  down 
upon  the  artery  behind  the  clavicle.  The  circulation  of  the  entire 
upper  extremity  is  thus  controlled. 

The  brachial  is  compressible  against  the  middle  of  the  humerus 
or   the   tourniquet   may  be  apphed  over  any  part  of  the  artery 

(Fig.  53)- 

The  radial  and  ulnar  are  not  compressible  except  just  above  the 
wrist;  and,  therefore,  bleeding  from  them  must  be  controlled  by 
direct  pressure  in  the  wound,  or  by  the  tourniquet,  or  by  com- 
pression of  the  brachial. 

The  palmar  arches  are  not  directly  compressible,  but  hemorrhage 
from  the  palm  is  controlled  by  grasping  firmly  a  round  body  as  a 
billiard  ball,  an  apple,  a  stone  wrapped  with  gauze,  and  bandaging 


EMERGENCY   HEMOSTASIS 


67 


the  hand  in  this  position.  If  this  is  not  practical,  the  tourniquet 
may  be  applied  to  the  forearm,  or  the  brachial  compressed. 

The  digital  arteries  are  always  easily  controlled  by  constriction  of 
the  finger  above  the  wound. 

The  femoral  artery  is  compressible  in  the  middle  of  the  groin 
against  the  ramus  of  the  pubes,  but  great  pressure  is  required  here 
to  control  its  flow  (Fig.  54).     It  may  likewise  be  compressed  lower 


Fig.  53. — Compression  of  brachial. 
{Moullin.) 


Fig.  54. — Compression  of  femoral. 
{Moullin.) 


down  against  the  shaft  of  the  femur.  The  tourniquet  is,  in  this  in- 
stance, the  safer  temporary  hemostatic,  a  compress  of  some  sort 
intervening  between  it  and  the  artery. 

The  popliteal  is  not  compressible.  Bleeding  must  be  controlled 
by  direct  pressure  or  by  compression  of  the  femoral. 

The  tibials  likewise.  They  may  also  be  controlled  by  flexing  the 
knee  forcibly  upon  a  pad,  holding  the  pad  in  place  by  a  cross  piece 
pressing  forcibly  against  the  popliteal  space,  and  in  turn  held  in 
place  by  a  bandage  around  the  flexed  leg  (see  Fig.  133,  page  183). 


68 


HEMORRHAGE 


Fig.  55. — Tamponing  the 
intercostal  artery.  R,  ribs; 
A,  artery;  W,  gauze.  (Wal- 
sham.) 


The  dorsal  and  plantar  arteries  can  best  be  controlled  by  direct 
pressure  or  by  compressing  the  tibials  and  peroneal  as  they  cross 
the  ankle. 

The  arteries  of  the  surface  of  the  trunk  most  likely  to  produce 
dangerous  hemorrhage  are  the  internal  mammary,  the  intercostals, 
and  the  deep  epigastric.     These  can  be  controlled  temporarily  only 

by  direct  pressure,  either  with  the  finger  or 
gauze  packing.  The  method  of  compressing 
the  intercostal  is  represented  in  Fig.  55. 

EPISTAXIS 

Epistaxis  is  a  form  of  hemorrhage  often 
troublesome  and  requiring  special  treatment. 
It  may  occur  in  one  or  both  nostrils.  The 
simpler  cases  are  relieved  by  the  erect  posi- 
tion, holding  the  arms  above  the  head,  by 
the  reflex  effects  of  cold  to  the  back  of  the 
neck,  or  by  pressure  over  the  root  or  sides  of  the  nose. 

If  these  measures  fail,  the  nostril  may  be  syringed  with  certain 
solutions:  hot  water;  antipyrin,  5  to  10  per  cent.,  which  is  especially 
recommended  in  the  Am.  Text-book  of  Surgery;  adrenalin,  i  to 
1000. 

The  patient  must  not  blow  his  nose,  as  this  ehminates  the  clot. 
In  the  more  severe  cases  try  tamponing  the  anterior  nares.  If  a 
nasal  speculum  and  a  good  mirror  light  are  available,  the  anterior 
nares  may  be  systematically  plugged  through  the  speculum  with 
adrenalin  gauze;  or,  by  such  means,  the  bleeding  point  may  be  dis- 
covered and  touched  with  the  point  of  the  cautery,  with  silver  ni- 
trate, or  with  chromic  acid. 

The  International  Journal  of  Surgery  gives  this  practical  sugges- 
tion: a  layer  of  cotton  is  wound  around  a  pen  holder  until  the  de- 
sired thickness  is  obtained  and  then  withdrawn.  The  cotton 
cylinder  is  then  moistened,  squeezed  dry,  and  inserted  into  the  nasal 
cavity.  If  the  projecting  end  is  now  moistened,  it  will  swell  up  and 
thus  produce  sufficient  compression. 

If  these  various  measures  fail,  then  the  posterior  nares  must  be 


EPISTAXIS 


69 


plugged.  For  this  purpose,  in  emergencies,  an  ordinary  soft  rubber 
catheter  is  available,  in  lieu  of  the  Bellocq  cannula  (Fig.  56).  It  is 
threaded  and  passed  directly  backward  through  the  inferior  meatus 
until  its  point  emerges  below  the  soft  palate.  The  thread  is  caught 
with  forceps,  drawn  out  through  the  mouth,  and  held  while  the 
catheter  is  withdrawn.  One  end  of  the  thread  projects  from  the 
nostril  and  the  other  from  the  mouth,  and  a  pledget  of  cotton  is 
tied  to  this  latter  end  and  traction  made  on  the  other,  by  which 


Fig.   56. — Tamponing  posterior  nares.      (Stewart.) 

means  the  tampon,  guided  by  the  index  finger,  is  drawTi  up  behind 
the  soft  palate  and  into  the  posterior  nares.  When  the  tampon  is 
tied  on  it,  it  is  a  good  plan  to  leave  the  thread  still  long  enough  to 
hang  out  of  the  mouth,  which  wall  greatly  facilitate  the  removal  of 
the  plug;  otherwise  forceps  are  required  or  else  the  tampon  will 
have  to  be  pushed  backward  into  the  pharynx.  Any  plug  put  into 
the  anterior  nares  must  be  secured  by  a  silk  thread,  lest,  becoming 
dislodged,  it  may  drop  into  the  larynx.  The  plugs  must  not  be 
left  in  for  more  than  two  days,  and  should  be  moistened  before 
removal  with  a  mild  antiseptic  solution.  Hertzfeld  (J.  A.  M.  A., 
March  13,  1909)  describes  a  case  of  serious  hemorrhage  from  the 
nasal  cavity  treated  with  perborate  of  soda.     A  strip  of  moist 


yo  HEMORRHAGE 

borated  gauze  H  inch  wide  was  covered  with  powdered  perborate 
of  soda  and  packed  tightly  into  the  anterior  nares.  The  hemorrhage 
ceased  immediately.  The  perborate  may  be  insufflated  directly 
into  the  cavity.  A  grayish-white  foam  immediately  issues,  nascent 
oxygen  is  liberated,  and  the  bleeding  checked. 


CHAPTER  IX 
WOUNDS.     GENERAL  PRINCIPLES 

DEFINITIONS 

A  wound  is  the  solution  of  the  continuity  of  the  soft  tissues,  due 
to  trauma. 

(a)  Subcutaneous  wounds  are  traumatic  lesions  of  the  deeper 
tissues  without  any  definite  break  in  the  skin.  Such  wounds  are 
more  commonly  called  ^'contusions." 

(b)  Open  wounds  are  those  accompanied  by  a  solution  of  con- 
tinuity of  the  integuments. 

1.  Incised  wounds  are  open  wounds  produced  by  sharp  or  edged 
instruments. 

2.  Stab  wounds  are  those  produced  by  sharp-pointed  instruments. 

3.  Punctured  wounds  are  those  produced  by  blunt-pointed  in- 
struments. 

4.  Lacerated  wounds  are  those  produced  by  tearing  or  crushing. 

5.  Gunshot  wounds  are  those  produced  by  projectiles;  shot,  bullets, 
cannon  balls. 

A  penetrating  wound  is  one  in  which  the  vulnerating  instrument 
reaches  a  body  cavity. 

A  perforating  wound  is  one  in  which  the  vulnerating  body  passes 
through  the  cavity. 

An  aseptic  wound  is  one  in  which  there  is  an  absence  of  the  germs 
of  inflammation. 

A  septic  or  infected  wound  is  one  in  which  the  germs  of  inflammation 
are  present. 

A  poisoned  wound  is  one  in  which  some  agent  destructive  to  tissue 
is  present. 

An  operative  wound  is  one  produced  by  the  surgeon's  knife,  and 
is  presumed  to  be  aseptic. 

71 


72  WOUNDS.      GENERAL   PRINCIPLES 

SYMPTOMS  AND  CHARACTERISTICS  OF  WOUNDS 

All  wounds  produce  more  or  less  pain,  hemorrhage,  and  loss  of 
function;  in  addition,  the  severer  wounds  produce  constitutional 
disturbances,  such  as  shock,  although  shock  may  also  occur  in  slight 
wounds.  Hemorrhage  depends  upon  the  number  and  size  of  the 
blood  vessels  involved;  pain,  upon  the  character  of  the  tissue  and 
the  extent  of  nerve  injury;  loss  of  function,  upon  the  amount  and 
kind  of  tissue  destroyed;  shock,  upon  the  mode  of  injury  and  the 
tissues  concerned. 

Subcutaneous  wounds  vary  widely  in  the  amount  of  tissue  di- 
vided. There  may  be  any  degree,  from  a  mere  strain  of  a  few  fibers, 
with  slight  intercellular  exudation  (bruises),  to  total  division  or 
widespread  laceration  of  the  various  layers  of  subcutaneous  tissue. 

The  pain  is  dull  and  aching.  The  hemorrhage  is  usually  slight, 
but  occasionally  may  be  dangerous.  If  the  hemorrhage  is  slight, 
it  produces  merely  subcutaneous  discoloration,  most  marked  in 
lax  tissues;  if  moderate,  it  produces  an  ecchymosis;  if  serious,  a 
hematoma. 

Contusion  of  the  nerves  may  produce  paralysis,  usually  tem- 
porary; or  the  nerve  may  be  completely  divided  in  subcutaneous 
wounds,  and  the  paralysis  be  permanent.  Shock  is  nearly  always 
present  in  some  degree. 

Treatment. — Subcutaneous  wounds  are  nearly  always  aseptic,  and 
an  effort  should  be  made  to  keep  them  so. 

The  first  principle  of  treatment  is  functional  rest.  It  may  be 
secured  in  bed,  or  by  the  use  of  splints,  slings,  or  bandages.  Mere 
voluntary  immobilization  is  not  often  sufficient.  Apply  a  cotton 
compress  and  bandage;  a  flannel  bandage  firmly  laid  on,  alone,  often 
gives  great  relief.  Evaporating  lotions,  in  the  case  of  superficial 
contusions,  often  do  good.  Tincture  of  arnica  and  witch-hazel  are 
common  domestic  remedies. 

The  following  solution,  freely  and  immediately  applied,  will  often 
prevent  a  ''blacked"  eye. 

I^ — Ammoni.  chloridi.,  gr.  v. 

Alcohol,  5    i- 


INCISED   WOUNDS 


73 


Cold,  while  often  giving  relief,  must  be  used  with  caution,  since  a 
too  long  application  will  lower  the  vitality  of  the  tissues  and  interfere 
with  repair,  or  will  even  precipitate  death  of  the  injured  tissues. 

Heat,  in  the  form  of  a  hot  water  bottle  or  hot  flannels,  is  better. 

If  the  extravasations  of  blood  are  moderate,  they  may  be  let  alone; 
or  if  persistent  and  interfering  with  repair,  they  may  be  aspirated. 
In  either  event,  after  the  inflammatory  symptoms  have  subsided, 
massage  is  useful  to  hasten  absorption,  promote  nutrition,  and  insure 
repair  and  restoration  of  function. 

In  those  cases  of  severe  injury,  where 
the  subcutaneous  hemorrhage  is  marked 
and  continuous,  and  where  a  hematoma 
forms,  the  skin  must  be  incised  without 
delay,  the  clots  turned  out,  the  wounded 
vessels  secured,  and  the  wound  subse- 
quently treated  as  an  open  one. 

A  workman  fell  from  a  scaffold  strik- 
ing the  gluteal  region.  He  seemed  at 
first  only  severely  bruised.  A  day  or  so 
later  it  became  apparent  that  a  large 
hematoma  had  formed.  It  was  aspir- 
ated and  a  large  quantity  of  blood  re- 
moved but  the  tumor  rapidly  reformed. 
It  was  opened  freely  and  in  the  torn  fibers 
of  the  gluteus  maximus  a  large  vessel  was 
found  still  bleeding.  The  cavity  was  a 
long  time  in  healing  but  no  infection  occurred. 

Incised  wounds  are  characterized  by  sharp  and  severe  pain,  free 
bleeding,  and  a  tendency  to  gape. 

The  slight  actual  destruction  of  tissue,  the  comparative  cleanli- 
ness of  a  cutting  instrument,  the  free  bleeding,  and  the  gaping 
present  conditions  most  favorable  for  transforming  an  infected  wound 
into  an  aseptic  one,  or  at  least  practically  so.  At  any  rate,  many 
presumably  infected  incised  wounds  heal  with  the  same  readiness 
and  absence  of  inflammatory  symptoms  as  aseptic  operative  wounds. 

Treatment. — For  the  arrest  of  hemorrhage,  ordinarily,  a  compress 
wrung  out  of  hot  water  or  normal  salt  solution  is  sufficient.     If 


Fig.  57- — Repair  of  in- 
fected incised  wound  of  thigh. 
{Veau.) 


74 


WOUNDS.      GENERAL   PRINCIPLES 


this  does  not  have  the  desired  result,  the  bleeding  vessels  are  to  be 
seized  with  artery  forceps  and  ligated.  The  hemostasis  must  be 
complete. 

The  wound  is  next  carefully  cleansed  of  clots  and  foreign  bodies, 
using  normal  salt  solution,  sterile  water,  or  very  weak  antiseptic 
solutions  Under  favorable  circumstances,  that  is  to  say,  if  there 
is  a  reasonable  certainty  that  the  wound  has  been  rendered  prac- 
tically sterile,  it  is  closed.  If  sepsis  is  feared,  a  small  tube  or  capillary 
drain  must  be  employed  (Fig.  57). 


Fig.  58. — Method  of  making  an  incision.     (Veau.) 


In  the  first  instance,  the  wound  is  as  carefully  closed  by  suture 
as  an  operative  one.  In  the  second  case,  sutures  are  employed,  but 
are  placed  further  apart,  leaving  the  wound  free  of  access  for  cleans- 
ing solutions  and  for  the  free  escape  of  the  exudates.  If  drainage 
is  employed,  it  may  usually  be  dispensed  with  after  the  third  day,  if 
no  sepsis  arises. 

It  is  safer  to  regard  all  large  incised  wounds  as  infected.  If  the 
wound  is  closed,  it  must  be  carefully  watched  for  signs  of  infection, 
and,  on  their  appearance,  be  reopened  without  delay;  or  the  sutures 
may  be  placed  and  left  untied  until  the  probabilities  of  infection 
have  been  determined.  A  wound  sealed  on  the  surface  and  infected 
below  is  a  calamity. 

After  repair  of  the  aseptic  incised  wound,  a  dressing  of  plain  sterile 
or  borated  gauze  is  applied,  and  over  this  absorbent  cotton  and 
bandage. 


OPERATIVE   WOUNDS  75 

In  certain  instances,  as  with  incised  wounds  of  the  face,  the 
dressing  may  be  dispensed  with,  the  slight  serous  exudate  being  al- 
lowed to  dry  and  form  a  crust,  which  protection  is  quite  adequate. 

Operative  wounds  are  incised  wounds,  and  the  aim  is  always  to 
make  and  maintain  them  aseptic.  Aside  from  preliminary  steriliza- 
tions, there  is  a  proper  method  of  making  these  wounds,  which  is 
essential  in  keeping  them  aseptic  and  promoting  repair. 


AM 
Fig.  59. — A  good  incision.     {Veau^ 


The  aim  should  be  to  do  as  little  violence  as  possible  to  any  tissues 
incised.  The  cutting  instrument  must  be  sharp,  and  the  tissues 
evenly  and  smoothly  divided. 

To  make  a  good  incision,  fix  and  slightly  stretch  the  tissues  on 
either  side  of  the  proposed  line  of  section,  with  the  left  thumb  and 
index  finger.  Never  put  the  skin  on  the  stretch  on  one  side  only. 
The  first  stroke  of  the  scalpel  should  divide  the  skin  for  the  whole 
length  previously  determined  (Fig.  58).     Decide  beforehand,  there- 


Fig.  60. — A  bad  incision,     iyeau.) 


fore,  the  probable  length  of  incision  required.  The  inexperienced 
operator  is  inclined  to  make  the  wound  too  short  and  when  subse- 
quently it  needs  to  be  lengthened  it  is  difficult  to  keep  it  straight. 
When  the  skin  and  subcutaneous  connective  tissue  are  divided, 
identify  the  deep  fascia  before  incising  it;  it  is  an  important  land- 
mark in  nearly  every  part  of  the  body.  All  the  layers  must  be  cut 
without  any  gashing  or  notching.  The  incision  in  the  deeper  layers 
should  not  be  quite  so  long  as  in  the  superficial  layer.  The  good 
incision  gives  an  equally  good  view  of  all  parts  of  the  cavity  (Fig.  59). 


76  WOUNDS.      GENERAL  PRINCIPLES 

The  bad  incision  creates  irregularities  which  interfere  with  inspection, 

hot  to  speak  of  repair  (Fig.  60). 

Stab  wounds  differ  from  incised  wounds  only  in  their  greater 
uncertainties.  Their  narrowness  and  depth  make  it  difficult  to 
determine  v\'hat  organs  and  tissues  have  been  involved. 

In  order  to  make  a  doubtful  diagnosis  sure,  to  repair  an  injured 
structure,  to  control,  hemorrhage,  and,  to  insure  antisepsis,  it  is 
often  necessary  to  enlarge  the  wound.  In  other  respects  these 
wounds  are  treated  on  the  same  general  principles  as  incised  wounds. 

Punctured  wounds  are  peculiarly  a  source  of  worry.  They  are 
most  prone  to  become  septic  for  two  reasons;  first,  infection  is  very 
likely  to  be  carried  into  the  wound,  and,  second,  it  is  Ukely  to  be 
retained. 

The  vulnerating  instrument  is  usually  unclean;  portions  of  it  may 
be  broken  off  and  retained;  other  foreign  bodies,  such  as  shreds  of 
clothing,  sources  of  infection,  may  be  pushed  in  and  overlooked, 
inasmuch  as  the  narrow  tract  makes  exploration  difficult.  The 
tissues  are  not  divided,  but  are  pushed  apart,  and  tend  to  close  as  the 
instrument  is  withdrawn.  The  vessels  are  little  wounded,  so  that 
bleeding,  the  best  agent  for  disinfection,  for  washing  out  the  invading 
microorganisms,  is  wanting. 

The  bottom  of  these  wounds  may  be  shut  off  from  the  surface,  so 
that  the  ox}'gen-hating  bacillus  of  tetanus  finds  there  a  congenial 
lodging. 

The  treatment  for,  all  these  reasons,  must  be  circumspect.  In 
doubtful  cases,  it  is  better  at  once  to  lay  open  the  wound  and 
thoroughly  disinfect  and  search  for  foreign  bodies.  In  any  event, 
the  wound  must  be  carefully  syringed  with  cleansing  solutions. 
Peroxide  of  hydrogen  is  particularly  indicated  if  tetanus  is  antici- 
pated. Antitetanic  serum  is  indicated.  If  suppuration  is  threat- 
ened, early  and  free  incision  and  drainage  are  imperative. 

Counter  openings  may  be  required  to  facilitate  the  removal  of 
foreign  bodies  or  inflammatory  products. 

Lacerated  wounds  are  characterized  by  the  great  destruction  of 
tissue,  comparatively  speaking.  ''They  are  peculiarly  the  product 
of  modern  times."  The  machinery  of  rapid  transit  and  manu- 
factory   is    largely    responsible.     Boiler    explosions    contribute    a 


LACERATED    WOUNDS 


77 


number.     Gunshot  wounds,  especially  of  the  face,  are  likely  to  be 
lacerated  wounds. 

The  manner  in  which  the  injuries  are  produced,  the  tearing  and 
crushing  of  the  tissues,  gives  such  injures  the  following  characteristics: 
(i)  There  is  slight  primary  hemorrhage. 

(2)  There  is  frequently  reactionary  or  secondary  hemorrhage. 

(3)  Shock  is  usually  present. 

(4)  Infection  seldom  fails  to  develop. 

(5)  Deformity  is  likely  to  result. 
The  following  are  the  reasons: 

(i)  Primary  hemorrhage  is  slight,  out  of  all  proportion  to  the 
destruction  of  tissue,  because  the  coats  of  the  torn  vessels  curl  up  and 
contract,  the  ragged,  uneven  surfaces  favor  coagulation,  and  the 
presence  of  shock  lowers  the  blood  pressure. 

(2)  Reactionary  hemorrhage  occurs  because  of  the  smaller  vessels 
losing  their  plugs  of  clotted  blood  when  the  blood  pressure  is  re- 
stored. Secondary  hemorrhage  occurs  because  of  the  suppuration, 
which  is  the  rule  rather  than  the  exception,  unless  prevented  by 
treatment. 

(3)  Shock  is  always  present  in  some  degree  because  of  the  injuries 
to  the  nerve  trunks.  In  crushing  injuries  to  the  extremities,  it  is 
sometimes  difl&cult  to  relieve  shock  until  the  mangled  nerves  are 
completely  divided  by  amputation.  Sometimes  under  these 
circumstances,  the  shock  is  immediately  fatal. 

(4)  Infection  is  coincident  with  the  injury  because  of  the  grime 
which  is  ground  into  the  tissues.  The  vitality  of  the  tissues  ad- 
joining those  which  were  killed  outright  is  greatly  lowered,  and  the 
power  to  resist  microbic  invasion  lost.  An  invading  germ  and 
lowered  vitahty  are  the  two  factors  always  essential  to  suppuration. 

Treatment  of  Lacerated  Wounds. — ^(i)  Hemostasls,  (2)  relief  of 
shock,  3)  antisepsis,  (4)  support. 

(i)  Hemostasis  is  usually  not  difficult.  It  may  be  necessary  to 
catch  up  a  bleeding  vessel  with  forceps  and  Kgate,  but  more  often 
pressure  with  gauze  pads  wrung  out  of  hot  normal  salt  solution 
suffices.  Unless  the  hemorrhage  is  severe,  sterilize  the  adjacent 
skin  with  soap  and  water,  bichloride,  or  alcohol,  before  beginning 
exploration. 


78  WOUNDS.      GENERAL   PRINCIPLES 

(2)  Shock  is  treated  on  general  principles.  Maintain  the  body 
heat,  lower  the  head,  and  keep  the  patient  quiet.  In  severe  cases, 
injections  of  adrenalin  and  salt  solution  are  to  be  employed.  (See 
shock.) 

(3)  Antiseptic  measures  follow  the  arrest  of  hemorrhage  and  shock. 
Begin  by  covering  the  wound  with  sterile  gauze,  and  then  scrub  the 
adjacent  skin  with  soap  and  sterile  water,  then  with  bichloride, 
1-2000,  and  finally  with  alcohol.  Next  cleanse  the  wound.  By 
repeatedly  flushing  with  normal  salt  solution  or  very  weak  bichloride 
or  other  antiseptics,  an  effort  is  made  to  rid  the  tissues,  as  much  as 
possible,  of  dirt  and  debris. 

Porter,  of  Fort  Wayne,  says  with  regard  to  cleansing  wounds 
(American  Medicine,  September,  1906),  that  it  is  an  easy  matter  to 
overdo  in  our  attempts  to  render  an  accidental  wound  aseptic.  By 
the  use  of  too  vigorous  scrubbing,  too  harsh  mechanical  means, 
too  hot  water,  or  too  strong  antiseptic  solutions,  more  harm  than 
good  may  be  done.  The  resisting  power  of  the  tissues  is  perhaps  the 
most  potent  single  factor  in  preventing  infection,  and  it  may  be 
diminished  by  too  much  antiseptic  zeal.  We  must  remember  that 
in  spite  of  our  efforts  some  germs  will  be  left  for  nature  to  take  care 
of,  and  we  must  not  make  it  impossible  for  her  to  do  it.  "Person- 
ally," says  Porter,  "I  find  myself  using  more  care,  more  time,  more 
patience,  more  soap,  more  water,  and  less  vigorous  scrubbing,  less 
curettement,  and  weaker  germicides." 

In  the  author's  practice  such  wounds  are  freed  of  grease  and 
grime  by  pouring  on  gasoline  and  then  painting  very  thoroughly 
with  iodine;  or  in  the  case  of  cavities  the  iodine  is  poured  into  the 
wound. 

It  is  not  always  possible  to  determine  to  what  extent  the  tissues 
are  fatally  injured.  In  the  case  of  crushed  wounds  of  the  extremi- 
ties, it  may  be  necessary  to  wait  until  a  line  of  demarcation  appears, 
so  that  no  useful  tissues  shall  be  unnecessarily  sacrificed. 

Drainage  is  a  matter  of  antisepsis.  It  is  a  sine  qua  non  in  the  case 
of  lacerated  or  crushing  wounds,  but  there  is  usually  little  trouble 
in  this  respect  for  the  reason  that  these  wounds  are  not  sutured 
and  drainage  is  provided  for  in  the  dressing. 

(4)  Suture  of  the  skin  wound  is  not  possible,  as  a  rule,  but  certain 


INFECTED   WOUNDS  79 

of  the  deeper  structures  may  demand  such  repair.  A  divided  nerve 
trunk,  tendon,  or  muscle  requires  approximation.  Sometimes 
coaptation  of  the  wound,  even  though  incomplete,  will  lessen  the 
time  required  for  granulation. 

The  dressing  must  fill  two  requirements;  it  must  absorb  the  dis- 
charge and  also  keep  out  infection.  The  most  commonly  employed 
dressing  consists  of  a  loose  but  liberal  covering  of  bichloride  or 
borated  gauze  applied  to  the  wound,  and  over  this  a  covering  of 
absorbent  cotton  held  in  place  by  a  bandage,  which  is  applied  for 
the  purpose  also  of  giving  equal  pressure  and  support  to  the  wounded 
tissues.  The  frequency  with  which  the  dressing  must  be  changed 
will  depend  upon  the  degree  of  infection. 

The  author  has  derived  much  satisfaction  in  the  treatment  of 
this  class  of  wounds  on  the  hands  from  the  use  of  the  ointment 
mentioned  on  page  472.  After  the  wound  has  been  cleansed  with 
iodine,  the  ointment  is  applied  and  the  whole  covered  with  gauze 
and  bandaged.  It  tends  to  relieve  tension  and  pain  and  promote 
repair.  The  gauze  does  not  adhere  to  the  surface  of  the  wound 
and  so  the  change  of  dressing  is  facilitated. 

The  aim  in  general  is  to  disturb  the  tissues  as  little  as  possible, 
and  no  change  is  made  except  to  meet  the  indications  for  some  phase 
of  sepsis. 

Infected  wounds  may  not  be  recognized  as  such  from  the  first, 
but  soon^the  processes  of  inflammation  manifest  themselves.  Pain, 
redness  and  swelling,  accompanied  by  certain  constitutional  states, 
such  as  fever  and  rapid  pulse,  are  the  cardinal  symptoms. 

The  sepsis  may  produce  no  results  more  severe  than  temporary 
disturbances  of  the  character  named.  On  the  other  hand,  it  may 
result  in  suppuration,  which  prolongs  repair  and  produces  un- 
welcome cicatrices;  or,  even  worse,  the  infection  may  spread  so 
rapidly  as  to  involve  extensive  areas,  rendering  the  tissues  brawny 
with  serous  exudates  and  overwhelming  the  heart  and  kidneys  with 
toxins  before  suppuration  has  time  to  appear.  It  is  these  un- 
certainties which  make  infection  so  much  to  be  feared,  and  make  its 
prevention  the  largest  element  in  the  treatment  of  ordinary  wounds. 
When  once  the  sepsis  has  a  definite  foothold  in  a  wound,  the  treat- 


8o  WOUJfDS.      GENERAL   PRINCIPLES 

me}it  has  two  objects:  to  destroy  the  germ  and  remove  and  neutrahze 
its  toxins;  and  to  support  the  tissues  in  their  struggle. 

Irrigate  the  wound  cavity  at  least  once  daily  with  weak  anti- 
septic solutions,  such  as  bichloride,  peroxide,  lysol,  or  iodine;  provide 
the  freest  exit  for  the  exudates,  employing  drainage  tubes,  if  there  is 
a  cavity.  Never  pack  a  suppurating  cavity  with  gauze.  Apply  a 
moist  gauze  dressing,  moistening  it  with  alcohol,  bichloride  or  boric 
acid,  or  other  antiseptic  solutions,  or,  what  is  perhaps  as  well,  with 
normal  salt  solution.  This  may  or  may  not  be  covered  with  ab- 
sorbent cotton.  Whatever  other  qualities  the  dressing  may  possess, 
it  must  be  absorbent.  Sometimes  in  the  case  of  the  extremities, 
prolonged  immersion  in  warm  normal  salt  solution  does  good. 

After  granulation  once  begins,  it  may  be  stimulated  and  the 
wound  kept  healthy  by  the  use  of  dusting  powders,  antiseptic  oint- 
ments, or  balsam  of  Peru.  The  latter  has  been  lately  very  highly 
recommended,  in  the  treatment  of  wounds  generally. 

(For  gas  bacillus  infection  see  page  285.  compound  fractures.) 


CHAPTER  X 
WOUNDS  OF  SPECIAL  REGIONS 

WOUNDS  OF  THE  SCALP 

Certain  anatomical  features  determine  the  special  character  of 
scalp  wounds,  and  must  be  kept  in  mind  in  prognosis  and  treatment. 

The  blood  vessels  converge  toward  the  vertex;  they  are  the 
occipital,  posterior  auricular,  superficial  temporal,  supraorbital 
and  temporal,  any  one  of  which  may  give  rise  to  troublesome  bleed- 
ing, and  all  of  which  are  subcutaneous  instead  of  subaponeurotic, 
as  elsewhere. 

They  are  firmly  connected  with  the  dense  tissue  of  the  scalp  and 
for  that  reason  do  not  readily  contract  when  divided;  for  this  reason 
the  bleeding  from  scalp  wounds  is  copious  and  without  much  tend- 
ency to  spontaneous  arrest.  The  vessels  are  somewhat  difficult  to 
catch  with  artery  forceps. 

The  aponeurosis  of  the  occipito-frontalis  is  the  dividing  line  in 
prognosis:  wounds  that  do  not  penetrate* it  are  less  likely  to  become 
infected,  nor  do  the  conditions  favor  spread  of  infection.  A  wound 
perforating  the  aponeurosis  is  always  a  matter  of  concern;  for,  ow- 
ing to  the  loose  cellular  tissues  which  connect  the  aponeurosis  with 
the  pericranium,  an  infection  may  spread  very  rapidly  and  in  every 
direction. 

All  scalp  wounds  are  presumably  infected,  yet  the  free  bleeding 
minimizes  the  infection,  and  the  rich  blood  supply  of  the  tissues 
favors  rapid  repair. 

Scalp  wounds  do  not  gape  unless  the  aponeurosis  is  divided,  and 
contused  wounds  often  resemble  incised  wounds. 

Contusions  may  result  in  the  formation  of  hematoma  beneath  the 
skin,  but  they  are  of  little  moment.  Evaporating  lotions  are 
sufficient  to  hasten  absorption. 

6  8i 


82  WOUNDS    OF    SPECIAL   REGIONS 

A  severer  injury  may  cause  a  hematoma  under  the  aponeurosis. 
Glancing  blows,  other  things  being  equal,  are  more  likely  to  cause 
these  tumors,  rupturing  the  vessels  of  the  subaponeurotic  areolar 
tissue.  Such  a  tumor  is  likely  to  be  extensive.  It  may  be  the 
source  of  error  in  diagnosis,  giving  the  examining  finger  the  sensa- 
tion of  a  depressed  fracture,  being  hard  around  the  borders,  and  soft 
in  the  center.  If  the  tumor  is  of  such  size  as  to  put  the  skin  greatly 
on  the  stretch,  it  may  be  punctured.  This  is  preferable  to  inci- 
sion, for  there  is  less  chance  of  infecting  the  exudate. 

Absorption  always  takes  place  so  that  the  least  interference 
possible  is  the  best  treatment. 

A  hematoma  may  form  under  the  pericranium,  usually  in  children 
in  whom  the  bone  has  a  rich  vascular  supply.  Here,  also,  it  is  ab- 
sorbed in  time,  and  intervention  is  rarely,  if  ever,  necessary. 

Open  Wounds. — The  treatment  of  these  wounds,  of  whatever 
character,  may  be  expressed  in  certain  general  formulae. 

The  first  step  consists  in  cleansing  the  hair  of  the  blood,  which  is 
not  always  an  easy  task.  Warm  water  is  best  to  dissolve  out  the 
clots,  or  peroxide  of  hydrogen. 

The  next  step  consists  in  remo\dng  more  or  less  of  the  hair,  de- 
pending upon  the  gravity  of  the  wound.  In  all  serious  cases,  the 
whole  scalp  must  be  shaved.  Begin  by  cutting  the  hair  with  the 
scissors,  and  then  apply  the  razor;  the  ''safety  razor"  facilitates 
this  work. 

Next  cleanse  the  scalp  -^dth  ether,  to  dissolve  the  oil  which  is  al- 
ways present,  and  follow  this  wath  alcohol;  other^s-ise  the  ether  will 
interfere  with  the  soap  and  water  cleansing  which  follows,  and  which 
is  freely  and  \igorously  applied. 

In  the  meantime,  a  light  gauze  packing  prevents  the  soap  and 
water  running  into  the  wound.  Once  the  scalp  is  cleansed,  the 
wound  itself  is  to  be  cleansed. 

Strong  antiseptics  are  distinctly  to  be  avoided.  Sterile  water, 
normal  salt  solution,  or  peroxide  are  perhaps  the  best.  An  irrigator 
or  sjTringe  is  not  to  be  used,  but  the  solution  may  be  squeezed  out 
of  a  compress  into  the  wound.  Be  assured  that  every  particle  of 
foreign  matter  is  out  of  the  wound  before  considering  repair. 


AVULSION   OF  THE   SCALP  83 

Complete  hemostasis  is  an  essential  to  rapid  healing,  and  the  time 
and  patience  spent  in  securing  it  are  by  no  means  lost.  If  the 
bleeding  vessels  cannot  be  ligated  in  the  ordinary  way,  the  ligature 
may  be  carried  on  a  needle  through  the  tissues  surrounding  the 
vessel.  The  oozing  may  be  entirely  controlled  by  a  few  minutes' 
pressure  with  a  hot  antiseptic  compress.  The  main  thing  is  not  to 
get  discouraged  or  be  in  too  great  a  hurry. 

The  cleansing  and  hemostasis  completed,  the  coaptation  follows. 
In  the  case  of  contused  wounds,  the  ragged  edges  are  to  be  trimmed. 
The  suturing  is  an  important  step  in  facilitating  reunion.  Even 
wounds  that  do  not  gape  heal  all  the  more  quickly  for  suturing,  silk 
being  probably  the  best  material. 

In  many  cases  of  incised  wounds  which  are  not  deep,  the  suturing 
may  be  firm  and  no  drainage  required.  In  the  great  majority  of 
cases,  however,  drainage  is  necessary,  and  may  be  secured  by  in- 
complete suture,  by  a  tube,  or,  following  Von  Bergman,  by  strips  of 
gauze  or  rubber  tissue. 

The  dressing  will  usually  consist  of  sterile  gauze  and  absorbent 
cotton  held  in  place  by  bandage.  In  the  case  of  minor  wounds, 
and  where  no  infection  is  feared,  it  is  sufficient  to  smear  the  line  of 
suture  with  sterile  vaseline  and  cover  with  flexible  collodion. 

If  a  large  segment  of  the  scalp  has  been  loosened,  every  effort 
must  be  made  to  readjust  and  suture  it  accurately,  though  the  drain- 
age must  be  ample.  Oftentimes  with  those  who  have  been  even 
almost  completely  scalped,  the  results  have  been  excellent. 

Flaherty  reports  a  case  of  complete  avulsion,  occurring  in  a 
laundry  worker.  There  were  areas  of  denuded  bone.  There  was 
no  shock  and  but  little  hemorrhage.  The  woman  who  was  alone 
at  the  time  of  the  accident  remained  perfectly  conscious  and  after 
extracting  herself  from  the  machinery,  stopped  the  motor  and 
wrapped  a  towel  around  her  head. 

Hot  boric  acid  compresses  were  applied  without  further  cleans- 
ing and  after  four  days  Thiersch  grafts  taken  from  the  thigh  were 
applied  to  one  side  of  the  head  and  a  week  later  to  the  other  side. 
The  denuded  bone  was  trephined  through  the  outer  table  that 
granulations  for  grafting  might  form.  Pursuing  this  line  of  treat- 
ment the  patient  was  enabled  to  leave  the  hospital  in  two  months 


84  WOUNDS    OF   SPECIAL   REGIONS 

with  head  covered  with  good  firm  skin.     (Annals  of  Surgery,  Feb., 
1914.) 

WOUNDS  OF  THE  PINNA 

Many  forms  of  injury  befall  the  ear.  It  may  be  bruised,  cut,  or 
lacerated,  and  much  or  little  of  it  lost.  Even  a  slight  loss  is  a  dis- 
figurement, and  any  very  serious  loss  of  tissue  results  also  in  some 
disturbance  of  hearing. 

A  laborer  came  into  the  City  Dispensary  with  half  an  ear  cut  off 
and  hanging  by  a  mere  thread  of  tissue.  The  sharp  edge  of  a  spade 
wielded  by  a  co-worker  had  produced  the  injury.  The  almost  dis- 
carded member  was  carefully  sutured  in  place  with  silk.  Some 
sloughing  occurred  along  the  edges  of  the  wound  but  eventually  the 
repair  was  complete  and  almost  without  a  scar. 

These  tissues  possess  great  vitality,  and  the  completeness  of  re- 
pair after  much  mutilation  is  often  surprising.  Large  portions  of 
the  ear  may  be  cut  off  completely,  and  yet  if  immediately  sutured 
in  careful  coaptation,  union  will  occur.  There  may  be  some  slough- 
ing along  the  line  of  union,  but  eventually  there  is  but  little  scar 
tissue  left.  In  every  case,  then,  of  incised  wound,  an  effort  must  be 
made  to  suture.  The  hemostasis  must  be  complete,  and  if  there  is 
much  laceration,  the  edges  of  the  wound  must  be  trimmed.  Silk 
is  the  best  suture  material  in  these  cases. 

WOUNDS  OF  THE  FACE 

Accidental  wounds  of  this  region,  more  than  any  others,  approxi- 
mate aseptic  wounds.  These  wounds  do  not  gape  much;  the  tissues 
are  very  vascular,  so  that  the  conditions  are  most  favorable  for  re- 
pair. The  chief  aim  is  to  avoid  scar  tissue  and  the  consequent  dis- 
figurement. To  attain  that  end  the  suturing  must  be  delicate,  the 
coaptation  perfect.  The  sutures  must  be  as  small  as  possible  and 
as  few  as  possible. 

The  subcutaneous  stitch  may  be  employed  if  the  wound  is  ex- 
tensive and  deep.  In  ordinary  incised  wounds  extensive  dressings 
may  be  dispensed  with,  and  the  line  of  suture  may  be  covered 
with  collodion  or,  as  Von  Bergman,  who  dislikes  collodion,  suggests, 


WOUNDS    OF   THE   EYELID 


85 


the  wound  may  be  amply  protected  by  the  scab  formed  by  the 
dried  exudates. 

WOUNDS  OF  THE  LIPS 

Wounds  of  the  lips  are  likely  to  bleed  considerably,   but  the 
hemorrhage  is  easily  controlled  by  compressing  the  lip  between  the 
thumb  and  index  finger,  and  then 
the  corollary  artery  may  be  lig- 
ated  on  each  side  of  the  wound. 

When  the  division  is  complete, 
begin  the  repair  by  suturing  the 
mucous  membrane  (Fig.  61)  with 
catgut.  Suture  the  skin  by  con- 
tinuous or  interrupted  suture  of 
fine  silk  or  catgut.  The  greatest 
care  must  be  exercised  when  the 
border  of  the  lip  is  reached;  the 
coaptation  must  be  exact  or  the 
result  will  be  a  disappointment. 

A  small  drain  in  the  skin 
wound  is  usually  advisable. 


Fig.  6r. — Suturing  wound  of  lip.     (Veau.) 


WOUNDS  OF  THE  TONGUE 

Wounds  of  the  tongue,  which  are  not  as  infrequent  as  one  might 
expect,  may  give  rise  to  a  disagreeable  hemorrhage. 

The  tongue  is  to  be  drawn  out  of  the  mouth  and  compressed  with 
the  fingers  above  the  wound  or  by  a  pair  of  forceps  covered  with 
rubber  tubing  or  with  gauze  (Fig.  62). 

Suture  the  bleeding  points,  employing  deep  sutures  of  catgut, 
No.  3.  Every  quarter  hour  the  mouth  should  be  washed  with  a 
solution  of  chloral,  2  grains  to  the  ounce,  until  the  oozing  and  pain 
have  subsided. 

WOUNDS  OF  THE  EYELID 

A  wound  of  the  eyelid  is  to  be  repaired  like  a  wound  of  the  lip, 
by  two  lines  of  suture.     First  suture  the  mucous  membrane  with 


86  WOUNDS    OF   SPECIAL   REGIONS 

fine  catgut.  Then  begin  the  suture  of  the  skin  at  the  free  border, 
where  the  edges  of  the  divided  tarsal  cartilage  are  to  be  very  ac- 
curately coapted  (Fig.  63).  If  drainage  is  used,  it  must  be  small 
and  project  from  the  middle  of  the  wound. 


Fig.  62, — Suturing  wound  of  tongue.     A,  tongue  controlled  by  tenaculum  forceps.     B,  first 
suture  passed  and  tied.     C,  second  suture  passed,  using  the  Reverdin  needle.     (Lejars.) 

WOUNDS  OF  THE  NECK 

One  has  but  to  consider  the  multipUcity  of  the  structures  in  the 
neck  to  realize  that  wounds  of  this  region  are  likely  to  be  complicated. 

Whether  the  wound  be  incised  or  contused,  a  stab  or  a  gunshot 
wound,  there  are  dangers  that  arise  from  hemorrhage,  asphyxia, 
and  infection. 

The  most  common  wounds,  perhaps,  are  those  which  arise  from 
attempts  at  suicide.  That  these  attempts  are  often  abortive,  and 
the  danger  done  much  less  than  one  might  expect,  are  due  to  the 
fact  that  the  tissues  are  yielding  and  the  vessels  recede  as  the  head 
is  thrown  back;  the  knife  may  be  directed  against  the  lower  jaw  or 
spend  its  force  on  the  cartilages  or  hyoid  bone;  the  arm  may  lose  its 


WOUNDS    OF   THE   NECK 


87 


force  at  the  moment  the  larynx  is  opened,  or  from  failing  resolution. 
In  these  attempts  at  suicide,  the  wound  in  right-handed  people  usu- 
ally begins  on  the  left  side  high  up,  and  runs  obliquely  downward  to 
the  right,  becoming  less  and  less  deep.  Not  infrequently  the  wound 
may  appear  jagged,  or  give  the  impression  of  two  or  three  slashes, 
from  the  folding  of  the  skin  before  the  pressure  of  the  knife  (Fig.  64). 

In  the  graver  cases,  hemorrhage  is  usually  the  first  consideration. 
If  a  carotid  is  wounded,  a  geyser  of  blood  spurts  out  and  the  patient's 
life  is  in  the  hands  of  the  first  comer,  for  there  is  no  time  to  call  for 
skilled  aid.  If  the  internal  jugular  is  wounded,  the  hemorrhage  is 
scarcely  less  dangerous  and  per- 
haps even  more  difficult  definitely 
to  control.  Air  may  enter  the 
venous  circulation  and  death  im- 
mediately ensue.  In  either  case 
anything  but  intelligent  first  aid 
will  fail. 

The  carotid  may  be  controlled 
by  pressure  downward  and  back- 
ward at  the  base  of  the  neck,  com- 
pressing the  vessel  against  the 
transverse  process  of  the  sixth  cervical  vertebra;  or  the  bleeding  may 
be  temporarily  controlled  by  direct  pressure  on  the  bleeding  vessel 
in  the  wound. 

When  the  surgeon  arrives  upon  the  scene,  he  finds  the  wound 
filled  with  a  great  clot,  for  it  cannot  be  expected  that  the  first  aid 
will  do  anything  more  than  partly  check  the  bleeding.  His  first 
effort  must  be  to  cleanse  out  the  clots  and  locate  both  ends  of  the 
bleeding  vessels,  clamp  them,  and  ligate.  Blind  clamping  of  the 
tissues  en  masse  is  absolutely  unsurgical.  If  the  ends  of  the  divided 
vessel  cannot  be  located,  the  wound  is  to  be  enlarged  over  the  course 
of  the  vessel,  using  the  anterior  border  of  the  sternocleidomastoid 
muscle  as  a  guide.  If  the  character  of  the  wound  or  the  region  pre- 
clude that,  then  the  artery  must  be  exposed  below  the  wound  and 
ligated.  It  may  happen,  especially  in  secondary  hemorrhage,  that 
the  carotid  on  the  opposite  side  also  may  need  to  be  ligated  either 
temporarily  or  permanently. 


Fig.  63, — Incised    wound    of    upper    lid. 
Tarsal  cartilage  sutured  first.      (Veau.) 


88 


WOUNDS    OF    SPECIAL   REGIONS 


The  internal  jugular  may  be  difficult  to  expose  and  ligate  because 
of  its  thin  and  friable  walls.  Even  small  openings  in  the  vessel 
may  call  for  circular  ligation,  for  lateral  hgation  is  usually  unsatis- 
factory.    Outside  of  the  hospital,  suture  can  scarcely  be  considered. 


<^'  yiKoM^, 


109S765    3  21 

Fig.  64. — Incised  wound  of  neck  involving  the  larynx,  i,  platysma;  2,  stemo-mastoid; 
3,  int.  jug.  vein;  4,  vagus  nerve;  5,  ext.  jugular  vein;  6,  com.  carotid  art.;  7,  upper  part  of 
wound  in  thyroid  cartilage  opening  into  larj'nx;  8,  sup.  thyr.  art.;  9,  st.  hyoid  muscle;  10, 
stemo-thyroid  muse.  • 


If  the  trachea^  in  its  upper  part,  or  the  larynx  is  opened,  it  is  better 
to  do  a  tracheotomy  lower  down  and  attempt  repair  of  the  wound. 
In  many  cases,  however,  if  the  wound  is  not  ^J^tensive,  it  is  sufficient 


INJURIES    TO   THE   EYE  8g 

to  close  the  wound  by  flexing  the  neck,  omitting  the  sutures,  and 
leaving  nature  to  repair  the  opening  in  the  air  passage. 

If  the  esophagus  or  pharynx  is  perforated,  repair  should  be  at- 
tempted; but  drainage  must  be  employed  and  the  external  wound 
left  partly  open,  for,  in  the  act  of  swallowing,  particles  of  food  may 
be  forced  into  the  wound  to  set  up  infection. 

If  infection  or  inflammation  of  the  respiratory  tract  arises,  it  is 
to  be  treated  on  general  principles. 

Divided  nerves  should  be  repaired  if  possible,  although  often  the 
difficulties  are  too  great  to  surmount. 

A  woman,  the  victim  of  a  murderous  assault,  was  brought  to  the 
City  Hospital  with  a  gaping  razor  cut  straight  across  her  throat. 
The  hemorrhage  had  been  checked  by  the  ambulance  surgeon  who 
had  applied  three  or  four  clamps.  She  was  anesthetized  with  some 
difficulty.  It  was  found  that  the  structures  connecting  the  hyoid 
bone  and  the  thyroid  cartilage  were  severed — in  other  words  the 
pharynx  was  opened  widely  and  with  each  inspiratory  effort  the 
epiglottis  protruded  into  the  wound. 

An  effort  was  made  at  an  anatomical  repair  and  with  some  success. 
The  mucous  membrane  was  fairly  wtII  coapted  with  interrupted 
sutures  of  plain  catgut. 

Next  all  the  small  bleeders  were  tied  and  the  muscle  ends  brought 
together  with  mattress  sutures  of  chromic  gut;  the  fascia  next  with 
chromic,  and  finally  the  skin  was  repaired  with  silkworm-gut. 
Rubber  tissue  drainage  was  used  on  either  side  of  the  middle  line 
extending  down  to  the  muscle  layer. 

Following  the  repair,  swallowing  was  exceedingly  painful  and  the 
secretion  of  mucous  excessive.  Rectal  feeding  was  necessary  for 
three  days. 

The  subsequent  course  of  the  case  was  remarkable.  Her  pulse 
and  temperature  remained  normal,  there  was  not  the  sHghtest  evi- 
dence of  infection  and  she  left  the  hospital  at  the  end  of  two  weeks 
with  a  fight  scar  as  the  only  evidence  of  her  terrible  experience. 

WOUNDS  OF  THE  EYE 

Morrison,  of  Indianapofis  (Indiana  Medical  Journal,  Feb.,  1907), 
has  defined  the  injuries  of  the  eye,  whose  treatment  must  most  often 


go  WOUNDS    or   SPECIAL  REGIONS 

be  instituted  by   the  general  practitioner.     From   the  diagnostic 
point  of  view,  he  classifies  them  under  two  heads-: 

(a)  Those  without  superficial  lesions  of  the  ball. 

(b)  Those  with  more  or  less  extensive  open  wounds. 

(a)  The  first  may  lead  the  practitioner  into  grievous  error  in  prog- 
nosis and  injudicious  lack  of  treatment.  No  blow  over  the  eye  should 
ever  be  considered  lightly.  While  the  majority  of  such  cases  lead  to 
no  serious  consequences,  the  exceptions  are  of  sufficient  frequency 
to  be  of  importance. 

It  is  possible  for  the  so-called  "concussions"  to  lead  to  subsequent 
inflammation  or  degeneration  of  the  deeper  structures  of  the  eye. 
So,  then,  though  no  treatment  is  to  be  instituted  in  the  absence  of 
symptoms,  yet  the  case  must  be  kept  under  observation  for  some 
time,  the  vision  tested,  irregularities  of  the  pupil  noted,  and  evi- 
dences of  inflammation  sought  for. 

On  the  other  hand,  there  may  be  a  hemorrhage  into  the  anterior 
or  posterior  chambers,  accompanied  by  pain,  protrusion  of  the  eye- 
ball, and  swelling  of  the  lids.  Under  such  circumstances,  put  the 
patient  to  bed  at  once  and  apply  ice  cloths  to  the  eye,  this  treatment 
to  be  kept  up  until  the  symptoms  begin  to  subside,  when  it  is 
probable  that  the  blood  has  clotted  and  the  hemorrhage  ceased. 

In  addition  to,  or  instead  of  hemorrhage,  there  may  be  disarrange- 
ment of  the  retina,  lens  or  iris,  accompanied  by  disturbance  or 
destruction  of  vision. 

Put  the  patient  to  bed  in  a  darkened  room,  and  drop  into  the  eye 
a  solution  of  atropine,  4  grains  to  the  ounce,  followed  by  the  ap- 
plication of  cold  cloths  for  at  least  twenty-four  hours.  Later  a 
bandage  is  to  be  appHed  and  the  patient  permitted  to  go  about. 

Any  subsequent  disturbance  calls  for  an  examination  by  an  oculist. 

(b)  Deep,  penetrating,  non-infected  wounds  of  the  globe  are  serious 
in  various  degrees,  depending  upon  the  region  involved,  though  they 
usually  heal  kindly.  Injuries  of  the  sclero-corneal  junction  or  ciHary 
body  often  lead  to  sympathetic  ophthalmia,  and  may  require  early 
or  late  enucleation. 

The  treatment  is  simple.  Prevent  infection  by  the  free  use  of 
boric  acid  solution,  followed  by  one  or  two  drops  of  the  atropine 


SUTURE    OF   THE   CONJUNCTIVA  9 1 

solution,  and  the  application  of  a  sterile  eye  dressing.     Rest  in  bed 
is  indicated. 

Every  wound  of  the  sclera  of  any  moment  requires  suture,  which 
is  the  best  means  of  preventing  infection.  Infected  wounds  require 
an  immediate  and  circumspect  treatment. 

If  the  vitreous  is  involved,  the  eye  is  almost  certain  to  be 
lost.  The  prognosis  is  somewhat  better  if  the  cornea  alone  is 
involved. 

The  eye  is  to  be  irrigated  with  warm,  sterile,  saturated  solution 
of  boric  acid,  followed  by  a  few  drops  of  the  atropine  solution,  the 
whole  to  be  repeated  every  two  or  three  hours,  until  the  redness 
passes  away.  In  the  meantime,  heat  or  cold  is  to  be  applied,  de- 
pending upon  which  gives  the  most  comfort,  except  in  the  case  of 
the  cornea,  where  heat  is  always  the  better  application. 

Morrison  recommends  as  the  best  eye  pad,  several  thicknesses  of 
sterile  gauze  held  in  place  by  a  single  thickness  of  bandage  or  a 
strip  of  adhesive  plaster  so  that  it  can  be  frequently  changed. 

To  sum  up,  then,  the  chief  ends  of  the  emergency  treatment  are 
two;  asepsis  and  conservation.  Only  very  rarely  will  the  question 
of  enucleation  present  itself  as  an  emergency.  The  careful  ex- 
amination which  should  be  given  every  injured  eye,  should  be  pre- 
ceded by  a  regulated  asepsis.  Prepare  the  hands;  prepare  the  orbital 
and  palpebral  regions  by  patient  washing  with  warm  sterile  water 
and  soap,  avoiding  all  pressure  or  rough  handling  which  may  aggra- 
vate the  ocular  lesions.  Cleanse  the  conjunctiva  of  the  grosser 
dirt  and  immediately  instill  a  few  drops  of  cocaine  solution.  In  a 
few  minutes  the  cleansing  of  the  globe  and  palpebrae  may  be  com- 
pleted without  pain,  and  a  careful  examination  made  and  the  treat- 
ment instituted. 

If  suture  is  required,  use  a  small  curved  needle  held  with  a  forceps, 
employing  catgut  No.  oo,  and  above  all,  a  minute  care  and  a  light 
hand. 

The  suture  should  not  pass  through  the  entire  thickness  of  the 
sclerotic  coat,  but  only  through  the  conjunctiva  or  the  most  super- 
ficial layers  of  the  sclera.  The  reunion  will  usually  be  perfect  if 
the  sutures  are  carefully  passed  and  slowly  tied.  (See,  also.  Foreign 
Bodies.) 


92 


WOUNDS    OF    SPECIAL   REGIONS 


WOUNDS  OF  THE  EXTREMITIES 

Wounds  of  the  extremities  call  for  varied  application  of  all  the  prin- 
ciples of  treatment  of  wounds,  hemostasis,  antisepsis,  and  suturing. 

Only  through  familiarity  with  these  principles  wdll  one  acquire 
address  in  the  management  of  the  individual  case,  for  no  two  injuries 
are  exactly  alike.  It  will  be  advantageous  to  exemplify  these  prin- 
ciples with  special  reference  to  wounds  of  the  extremities. 


INCISED  WOUNDS  OF  THE  WRIST 

Such  wounds  are  frequent  and  their  repair  is  usually  left  to  the 
junior  surgeon;  the  task  is,  however,  no  light  one  and  the  functional 


II.P 


.ecu 


jr.k    ')^p      '^"^ 


Fig.  65. — Cross  section  showing  relations  of  the  various  tendons  at  the  wrist-joint. 
A^.  /?.,  radial  nerve;  L.F.P.,  long  flexor  of  the  thumb;  A.R.,  radial  artery;  G.P.,  palmaris 
longis;  N.M.,  median  nerve;  L.F.,  flexors  of  the  fingers;  A.C.,  ulnar  artery;  N.C.,  ulnar  nerve; 
C.P.,  ext.  carp,  ulnar;  C.P.D.,  ext.  min.  dig.,  C.C.D.,  ext.  com.  digitorum;  L.E.P.,  ext.  long, 
pollicis;  R,  extensors  carp,  rad.;  M.P.;  supinator  longus  extensor  brev.  poUicis. 

results  are  often  a  source  of  embarrassment  to  the  operator.  To 
locate  and  identify  all  these  tendons  and  nerves,  to  get  the  proper 
ends  in  contact,  to  repair  them  and,  above  all,  to  avoid  infection 


WOUNDS    OF   THE   EXTREMITIES 


93 


requires  no  end  of  patience  and  no  little  skill.     The  management  of 
these  wounds  is  largely  a  matter  of  applied  anatomy. 

In  the  more  superficial  wounds  the  palmaris  longus  alone  is  di- 
vided, a  quite  small  tendon  in  the  middle 
line  of  the  wrist. 

A  little  deeper  on  the  radial  side  of 
the  middle  line,  the  flexor  carpi  radialis 
may  be  involved;  or  far  out  on  the  ulnar 
side,  the  flexor  carpi  ulnaris,  in  the  line 
of  the  pisiform  bone. 

If  a  still  deeper  plane  is  reached  the 
radial  artery  on  the  radial  border,  the 
ulnar  artery  on  the  ulnar  border  may  re- 
quire a  ligature.  The  ulnar  nerve  lies  to 
the  ulnar  side  of  the  ulnar  artery,  and 
little  deeper.  In  the  middle  line  in  this 
deeper  plane  are  the  flexors  of  the  fingers 
and  the  median  nerve  (Fig.  65) . 

The  bleeding  in  such  cases  is  usually 
copious. 

Begin  the  treatment  by  elevating  the 
arm  and  applying  circular  constriction  for 
temporary  hemostasis  (Fig.  66) . 

Next  sterilize  the  field  and  then  the 
wound  itself.  Separate  the  lips  of  the 
wound,  locate  and  clamp  the  superficial 
veins  (Fig.  67).  These  are  not  of  much 
importance  yet  are  large  enough  to  make 
troublesome  bleeding.  Search  for.  the 
artery;  both  ends  must  be  ligated,  the 
companion  vein  included. 

It  may  be  necessary  at  this  time  to 
enlarge  the  wound,  for  the  skin  may  be 
much  less  extensively  involved  than  the 
deeper  parts. 

It  is  of  great  assistance  to  mobilize  the  lips  of  the  skin  in  order  to 
expose  and  facilitate  the  repair  of  the  deeper  structures.     Remove 


Fig.  66. — Incised  wound  of 
wrist.  Tourniquet  applied. 
(^Veau.) 


94 


WOUNDS    or    SPECIAL    REGIONS 


Fig.  67. — Incised    wound    of    wrist.     Bleed- 
ing vessels  clamped.     (Veau.) 


Fig.  68. — Incised    woxind    of    wrist. 
Vessels  ligated.     (Veau.) 


Fig.  69. — Wound  at  bend  of  elbow,      i,  Basilic  vein;  2,  median  cephalic  vein;  3,    biceps 
tendon;  4,  bicipital  fascia;  s.  brachial  artery;  6,  brachial  vein;  7,  median  nerve. 


WOUNDS    OF   THE   EXTREMITIES  95 

the  tourniquet,  complete  the  hemostasis,  and  proceed  to  determine 
the  injuries  to  tendons  and  nerves.  (For  methods  of  repair  see 
page  347.) 


WOUND  AT  THE  BEXD  OF  THE  ELBOW 

The  importance  of  the  structures  at  the  flexure  of  the  elbow  call 
for  special  reference  to  incised  wounds  in  this  region.  They  are 
not  infrequent. 

Superficially,  on  the  inner  side,  is  the  median  cephalic  vein;  on 
the  outer  the  basilic  vein;  below  these  the  bicipital  fascia,  an  im- 
portant landmark  just  beneath  which,  in  the  middle  line  lies  the 
brachial  artery  with  its  vein  to  the  inner  side.  The  median  nerve 
lies  also  to  the  inner  side;  and  deeply  placed  in  the  middle  line  is 
the  tendon  of  the  biceps.  Failure  to  repair  any  of  these  structures 
may  lead  to  serious  disability.  The  bicipital  fascia  should  be  re- 
paired by  a  separate  line  of  sutures  (Fig.  69). 

A  STAB  WOUND  OF  THE  THIGH 

(Fig.  70.) 

The  femoral  has  been  w^ounded  and  the  hemorrhage  is  furious. 
Direct  an  assistant  to  make  firm  digital  pressure  over  the  artery 
as  it  crosses  the  pubes,  nor  must  this  pressure  be  relaxed.  If  his 
fingers  tire,  a  second  assistant  may  press  upon  the  fingers  of  the 
first  (Fig.  71).  Enlarge  the  wound  freely  in  both  directions  in  the 
course  of  the  artery.  Sponge  out  the  clots;  identify  the  aponeurosis 
and  divide  it  in  order  to  expose  the  artery;  isolate  the  artery  by 
careful  blunt  dissection  and  find  the  two  ends,  which  is  often  difficult 
when  the  artery  is  completely  divided  (Fig.  72). 

When  both  ends  are  found,  ligate  with  catgut  No.  3,  or  silk  No.  2, 
(Fig.  73).  Tie  the  injured  vein  next  both  above  and  below.  It  is 
to  be  tied  separately  from  the  artery  (Fig.  74).  The  possibility  of 
including  a  nerve  in  the  ligature  must  always  be  borne  in  mind  and 
no  ligature  is  to  be  finally  tied  until  certain  that  no  nerve  is  to  be 
thus  compressed,  to  become  later  a  source  of  pain.     Remove  the 


96 


WOUNDS    OF    SPECIAL   REGIONS 


pressure  and  catch  any  more  vessels  that  might  bleed;  employ  free 
drainage  and  suture  incompletely. 

Apply  sterile  gauze  dressing,  absorbent  cotton,  and  a  bandage, 
making  moderate  pressure,  and  maintain  the  limb  in  moderate  ele- 
vation.    Renew  the  dressings  on  the  third  day,  and  if  there  are  no 


Fig.  70. — Stab  wound  of  thigh. 

(IVOM.) 


Fig.  71. — Stab  wound  of  thigh.  Com- 
pressing artery  while  the  wound  is  en- 
larged.     (TVoM.) 


complications,  remove  the  drainage.     Remove  the  sutures  about 
the  eighth  day. 

Certain  complications  may  arise.  If  the  ligatures  were  imperfect, 
hemorrhage  may  ensue;  the  operation  has  to  be  repeated  and  the 
vessels  tied  again.     If  infection  occurs,  if  the  temperature  reaches 


WOUNDS   OF   THE   EXTREMITIES 


97 


Fig.  72. — Exposing  the  wounded  vessel.     (Veau.) 


Fig.  73. — Isolating  and  ligating  the  artery.     Fig.  74- — Ligating     the     vein.     {Veau.) 
iVeau.) 


98  WOUNDS    OF    SPECIAL   REGIONS 

101°  F.,  open  up  the  wound  and  establish  better  drainage,  which  is 
the  best  means  of  preventing  secondary  hemorrhage.  Gangrene 
sometimes  follows  the  ligation  of  a  main  artery.  Watch  the  tem- 
perature of  the  extremity  and  look  for  pulsation  in  the  arteries  be- 
low the  Ugature.  If  pulsation  is  present,  be  in  no  haste  to  amputate. 
If  gangrene  does  not  develop  before  the  fourth  day,  it  is  not  likely 
to  do  so. 

Crushing  and  lacerating  wounds  of  the  extremities,  as  Lejars 
says,  give  rise  to  the  most  perplexing  problems  of  emergency  surg- 
ery. The  questions  present  themselves  in  this  form:  To  amputate, 
or  not  to  amputate?  and  if  the  latter,  when,  at  what  point,  and  by 
what  method? 

In  order  not  to  be  vacillating  in  his  treatment,  every  doctor  must 
have  his  principle  of  action  settled  once  for  all. 

Lejars  states  his  guiding  principle  and  rule  of  action  in  this  manner: 
Above  all,  save  the  patient's  life;  save  the  limb  wherever  possible, 
or  at  least  limit  the  mutilation  to  the  minimum. 

Clinically,  he  places  these  injuries  in  two  groups:  (a)  those  in 
which  a  segment  of  the  limb  is  crushed  or  otherwise  injured  without 
peripheral  involvement,  and  (b)  injuries  extending  from  the  hand  or 
foot  upward. 

(aj  Suppose  a  case:  An  arm  has  been  run  over  by  the  wheels  of  a 
heavy  vehicle.  The  member  is  flail-Uke,  although  the  skin  is  not 
broken,  and  there  are  no  particular  points  of  bleeding.  Palpation 
through  the  skin  over  the  injured  segment  shows  that  the  deeper 
structures  have  been  reduced  to  a  pulp,  both  muscle  and  bone. 

Still,  below  the  wound,  the  radial  and  ulnar  arteries  are  found  to 
pulsate.  This  is  an  absolute  indication  against  amputation.  The 
immediate  treatment  must  be  limited  to  a  careful  disinfection  of  the 
member,  the  repair  of  any  superficial  wounds,  a  complete  envelop- 
ment in  absorbent  cotton,  and  immobilization. 

The  immobiUzation  is  an  essential  feature,  for  by  that  means 
any  bending  and  stretching  of  the  vessels  is  prevented  and  repair 
favored.  If  the  skin  is  broken  and  the  bone  crushed  or  shattered 
and  exposed,  the  injury  is  a  compound  fracture  and  is  to  be  dealt 
with  accordingly,  but  the  prognosis  always  depends  upon  the  blood 
supply. 


WOUNDS   OF   THE   EXTREMITIES  99 

If  in  the  case  instanced,  there  is  absolutely  no  pulsation  in  the 
principal  arteries,  it  is  certain  that  a  part  of  the  limb  is  lost;  yet  an 
immediate  operation  is  not  indicated.  There  are  two  reasons  for 
this;  first,  that  the  shock  may  subside,  and  second,  that  too  much 
of  the  limb  may  not  be  sacrificed,  which  latter  an  immediate  ampu- 
tation nearly  always  means. 

Proceed  to  a  most  rigorous  disinfection  and  await  a  line  of  demar- 
cation. This  is  the  rule  to  which  there  are  two  exceptions,  one 
apparent,  and  the  other  actual. 

If  the  injury  is  a  crushing  one  and  the  member  hangs  by  shreds  of 
tissue,  there  is  absolutely  no  use  in  waiting;  but  the  completion  of 
the  ablation  does  not  require  an  amputation,  it  is  merely  what 
Lejars  terms  a  "regularization." 

Trim  up  the  tissues  sparingly  and  remove  enough  bone  that  a 
proper  stump  may  be  formed,  and  then  patiently  cleanse  the  wound 
with  hot  sterile  water  or  normal  salt  solution,  followed  by  alcohol. 
Suture  completely  and  then  cover  the  wound  with  sterile  gauze 
saturated  with  alcohol;  finally  cover  all  with  a  thick  layer  of  cotton 
firmly  bandaged. 

Almost  always  by  this  means  a  better  functional  result  may  be 
obtained  than  by  a  formal  amputation  quite  above  the  site  of 
injury.  ,,      4 

There  is  an  actual  exception  to  the  rule  of  conservatism.     The 
case  is  seen  late  and  there  are  already  signs  of  approaching  infection. 
It  is  not  safe  to  delay  and  risk  the  sepsis  which  menaces.     It  is  better 
under  such  circumstances,  to  proceed  to  immediate  amputation. 

(b)  Crush  or  laceration  extending  from  the  hand  or  foot  upward. 

Suppose  you  are  called  to  treat  the  foot  and  part  of  the  leg,  or  a 
hand  and  part  of  the  f  orearm,  which  have  been  crushed  and  lacer- 
ated. The  member  appears  injured  beyond  remedy.  Will  you  imme- 
diately proceed  to  amputate?  By  no  means — or  at  least,  not  as  a 
rule. 

If  the  case  is  seen  immediately,  the  first  effort  should  be  devoted 
to  combating  shock  and  infection. 

It  is  not  altogether  on  account  of  shock  that  one  waits;  there  are 
other  even  more  important  reasons.  The  first  is  that  you  may  not 
amputate  high  enough;  the  second,  that  you  may  amputate  too  high. 


loo 


WOUNDS    OF    SPECIAL   REGIONS 


One  cannot  always  determine  from  the  first  how  high  the  devitalized 

tissues  extend.  There  may  be  vascular  injuries  or  muscular  lacera- 
tions which  are  concealed  by  a  sound  integument,  and  which  may 
later  be  the  source  of  gangrene.  Out  of  this  grows  the  necessity  of  a 
secondary  amputation,  which  is  always  a  matter  of  chagrin  to  the 
surgeon  and  an  element  of  danger  to  the  patient. 

On  the  other  hand,  tissues  which  appear  devitalized  may  finally 
survive  and  thus  preserve^a  function  which  might  otherwise  have 
been  sacrificed. 

It  is  true  that  a  few  inches  more  or  less  of  the  arm  or  leg,  for  in- 
stance, may  make  no  great  difference  in  the  usefulness  of  the  stump; 
it  is  quite  otherwise  when  the  question  is  that  of  amputating  im- 
mediately above  or  below  the 
elbow  or  the  knee,  or  through 
them.  Nor  do  rules  of  con- 
servation apply  with  equal 
force  to  the  foot  and  the  hand. 
Injuries  of  similar  degree 
affecting  the  upper  or  lower 
extremity  demand  different 
treatment,  because  of  the  much 
greater  freedom  of  collateral 
circulation  in  the  former,  render- 
ing gangrene  less  probable. 
Where  conservatism  or  ex- 
cision would  be  proper  in  the  upper  extremity,  amputation  would 
be  called  for  in  the  lower  limb. 

Extensive  comminution  and  loss  of  bone  of  the  foot  mav  demand 
amputation  because,  if  saved,  the  member  may  be  useless  as  a  means 
of  locomotion,  and  should  give  way  to  a  vastly  more  useful  artificial 
limb. 

Great  laceration  of  the  soft  parts  of  the  foot,  with  free  comminu- 
tion of  bone  and  injury  to  vessels,  always  demands  amputation; 
for  the  destruction  of  the  skin  of  the  heel  and  sole  will  result  in  a  cica- 
trix which  can  never  bear  the  weight  of  the  body  and  may  never  be 
anything  but  a  source  of  suffering  and  discomfort  to  its  possessor. 
But,  aside  from  these  exceptions  and  others  to  be  noted,  the  rule 


Fig.  75. — Ball  of  gauze  for  support  of  fingers. 
(Marsee.) 


WOUNDS    OF    THE   EXTREMITIES 


lOI 


Fig.  76. 


-Thumb  pinched  off  leaving  square- 
ended  stump.     {Marsee.) 


holds  in  this  class  of  injuries,  to  avoid  amputation  and  devote  one's 
skill  to  preventing  infection.     The  prevention  of  infection  is  the 
sine  qua  non;  if  the  efforts  in  this  direction  are  going  to  be  half- 
hearted, it  is  better  to  amputate 
at  once. 

Immediate  ampidativn,  again, 
is  indicated  if  the  wound  is 
seen  some  hours  after  the  acci- 
dent, and  is  found  soiled  and 
dirty  and  manifestly  infected. 

Under  these  conditions,  con- 
servation is  not  the  best  course, 
for  there  are  too  many  chances 
that  the  attempt  at  disinfection 
will  fail;  that,  in  spite  of  the 
best  efforts,  sepsis  will  arise. 
Or,  if  there  are  already  present 
the  symptoms  of  dangerous  sepsis,  it  is  no  longer  a  question  of 
saving  a  limb,  but  of  saving  a  life,  and  it  will  be  the  part  of  con- 
servatism to  amputate  well  above  the 
suspected  level. 

With  regard  to  the  conservative 
treatment  of  these  severe  crushing  and 
lacerated  injuries  of  the  hands  and  feet 
which  most  surgeons  would  be  prone  to 
amputate,  Reclus,  of  Paris,  has  empha- 
sized the  value  of  thorough  and  patient 
disinfection  of  the  skin  and  then  of  the 
wound,  together  with  a  trimming  away 
of  the  devitalized  fragments  of  skin  and 
bone.  He  then  ''embalms"  the  mem- 
ber in  gauze  saturated  with  an  anti- 
septic pomade,  crowded  into  all  the 
recesses  of  the  wound,  and  the  whole 
covered  by  a  thick  dressing  of  absorbent  cotton  and  bandaged.  This 
dressing  is  left  undisturbed  until  repair  is  complete,  unless  the  tem- 
perature should  rise  or  a  disagreeable  odor  develop. 


Fig.  77. 


— Same, 
pleted. 


Amputation  com- 
{Marsee.) 


I02 


WOUNDS    OF    SPECIAL   REGIONS 


Joseph  Marsee  (Ind.  Med.  Jour.,  April,  1896)  has  made  some 
useful  observations  with  respect  to  the  treatynent  of  common  injuries 
of  the  hand,  which  are  well  worth  repeating  and  which,  as  he  points 

out,  appeal  especially  to  the 
young  man  just  beginning  his 
life's  work,  for  such  will  prob- 
ably constitute  the  bulk  of  his 
surgical  practice  for  some 
years.  There  is  a  natural 
tendency,  in  the  popular  mind, 
to  measure  an  injury  by  the 
size  of  the  member  involved, 
and  the  man  who  would  insist 
upon  the  best  advice  in  other 
cases,  will  fly  to  the  nearest 
doctor's    sisn    when    ''onlv    a 


Fig. 


78. — Amputation  of   index  finger.     Head 
of  metacarpal  retained.     {Marsee.) 


finger''  is  involved.  But  ^larsee  concludes,  from  his  owtl  experi- 
ence, that  the  young  practitioner  is  an  accomplice  in  spoiUng  a 
good  many  hands  before  he  learns  to  do  them  justice.  On  the 
other  side,  it  is  not  too  much  to  say  that  the  best  human  skill  is 
none  too  good  when  employed 
in  repairing  injuries  of  the 
most  mechanically  perfect 
human  member. 

The  majority  of  these  in- 
juries occur  in  workers  with 
machinery;  the  hand,  therefore, 
is  always  soiled  and  generally 
greasy.  This  grease  must  first 
be  removed.  Nothing  is  better 
for  this  purpose  than  ordinary 
gasoline  or  benzine,  which  may 
be  poured  into  the  hand 
directly  from  the  bottle.  The 
fluid  will  find  its  way' into  the 

smaUest  recesses  of  the  "wound,  washing  out  the  grime  and  preparing 
the  way  for  the  other  antiseptics.     The  benzine  is  poured  on  until 


Fig.  79. — Amputation  of  index  finger. 
Head  of  metacarpal  removed  making  much 
more  sightly  hand.      {Marsee.) 


INJURIES    TO    THE   HAND 


103 


Fig.  80. — Loss   of  ring  finger. 
Dorsal   view.      (Marsee.) 


all  the  grease  is  removed,  and  the  disin- 
fection is  completed  in  the  ordinary  way. 
Even  slight  wounds  of  the  fingers  and 
palms  should  be  treated  by  enforced  rest 
by  a  splint  or  plaster-of-Paris  dressing, 
complete  enough  to  preclude  all  motion. 
This  prophylaxis  is  not  regarded  as  un- 
necessary by  those  who  have  seen  the  most 
marked  deformities,  the  gravest  constitu- 
tional disturbances,  and  even  death,  re- 
sult from  trifling  wounds  of  the  hand. 
Enforced  rest  which  leaves  nothing  to 
chance,  to  caprice,  or  the  patient's  med- 
dling is  alone  reliable.  Under  such  treat- 
ment, the  rapidity  with  which  alarming 
symptoms  sometimes  disappear  is  truly  remarkable.     If  a  plaster 

casing  is  used,  it  should  extend  from 
several  inches  above  the  -vsTist  to 
the  extreme  tips  of  the  fingers,  the 
thumb  being  also  enclosed  if  neces- 
sary. 

WTien  finger  wounds  are  extensfve 
and  parallel  with  the  long  axis,  it  is 
better  not  to  suture  them  at  once, 
for  the  swelling  v>^l\  generally  be  ex- 
tensive and  the  stitches  will  cut  out. 
After  the  inflammation  has  subsided, 
the  edges  may  be  freshened  and  ap- 
proximated. Nor  does  Marsee  ad- 
vise immediate  splinting  in  the  case 
of  crushing  injuries  of  the  fingers,  for 
fear  that  the  circulation  may  be  in- 
terfered with.  However,  that  the 
crushed  member  may  not  be  wholly 

Fig.  81.— The  loss  of  the  ring  finger        unsupported,     a     SOft      ball     COVered 

is  hardly  noticed  when  the  distal  half      ^.j^j^  cotton  and  Wrapped  with  gauze 

of    the    metacarpal    bone    is    excised.  ^  " 

{Marsee.)  Is  applied  to  the  palm  so  that  the 


I04 


WOUNDS    OF   SPECIAL   REGIONS 


fingers  may  be  spread  out  over  it  comfortably  (Fig.  75),  and  the 
whole  dressed  with  absorbent  cotton  and  lightly  bandaged.  The 
ball,  as  ^Marsee  indicates,  though  unsightly  and  bulky,  has  no  other 
fault;  it  is  light,  absorbent  and  wonderfully  comfortable,  and  needs 
only  a  trial  to  be  appreciated  and  adopted.  It  should  be  used 
until  the  tissues  are  beyond  danger,  though  it  takes  several  days, 
a  week  or  a  month.  No  time  is  lost,  for  healing  cannot  begin  until 
vitality  is  restored,  and  this  will  always  be  slow  in  such  cases,  a 

fact  which  should  be  brought 
thoroughly  to  the  patient's 
knowledge  from  the  beginning, 
that  the  doctor  may  not  be 
blamed  for  the  tardy  convales- 
cence. 

With  regard  to  methods  of 
amputating  fingers,  opinion  is 
divided  on  the  question  as  to 
which  is  the  more  desirable,  a 
palmar  flap,  or  a  slightly  longer 
linger  with  a  dorsal  flap  cover- 
ing the  stump. 

There  can  be  no  douot  that 
a  palmar  flap  is  desirable,  and 
Marsee  believes  in  securing  it, 
even  at  the  expense  of  sacrific- 
ing more  of  the  finger.  If  more 
than  half  the  phalanx  is  gone, 
it  is  always  better,  in  his  opinion,  to  amputate  at  the  joint  line  and 
thus  avoid  a  flexed  stump. 

If  a  portion  of  the  distal  phalanx  remains,  the  nail  should  be  re- 
moved and  the  matrix  dissected  before  the  flap  is  adjusted,  or  some 
deformed  fragment  of  nail  may  be  left  to  vex  the  patient.  It  is 
better,  in  removing  a  finger  at  a  joint,  to  cut  off  the  knobby  pro- 
jections of  the  condyles  on  the  palmar  surface  and  to  scrape  off  the 
exposed  cartilage. 

If  the  finger  is  pinched  off'  squarely,  one  must  always  insist  in  re- 
moving enough  of  the  bone  to  give  a  good  flap,  for  if  the  patient  has 


Fig.  82. — The  stump  of  the  index  finger 
falls  away  from  thumb  when  head  of  middle 
metacarpal  has  been  removed.      (Marsee.) 


WOUNDS    OF    THE  VULVA  I05 

his  way  and  the  stump  heals  by  granulation,  the  result  will  be  unsatis- 
factory and  the  doctor,  eventually,  will  have  to  bear  the  blame 
(Figs.  76,  77). 

If  the  whole  finger  requires  amputation,  the  head  of  the  meta- 
carpal bone  will  require  special  attention  and  the  procedure  will  be 
different  with  the  different  fingers. 

Remove  the  heads  by  oblique  section  in  the  case  of  the  index  and 
little  fingers  (Figs.  78,  79).  Generally  remove  the  head  of  the  meta- 
carpus in  the  case  of  the  ring  finger,  cutting  back  far  enough  to  let 
the  heads  of  the  adjacent  bones  fall  together  (Figs.  80,  81). 

Do  not  remove  the  metacarpal  head  of  the  middle  finger  unless  the 
appearance  of  the  hand  is  the  chief  consideration.  Marsee  states 
as  the  reason  for  this,  that  it  tends  to  let  the  other  fingers  fall  away 
from  the  thumb  and  thus  interferes  with  ready  apposition  (Fig.  82). 

WOUNDS  OF  THE  VULVA  AND  VAGINA 

The  chief  danger  in  wounds  of  these  parts  is  hemorrhage,  especially 
When  the  vulva  is  involved  and  its  venous  plexuses  torn.  These 
wounds  may  be  contused,  lacerated  or  punctured,  and  more  fre- 
quently occur  from  falls  astride  some  object,  and  by  that  means  the 
bulb  of  the  vagina  is  crushed  against  the  ramus  of  the  pubes. 

Forcipressure  and  ligation  may  be  ineffectual  to  control  the  bleed- 
ing and  often  the  only  recourse  is  tamponade,  first  disinfecting  the 
wound  and  the  region  adjacent,  and  afterward  applying  a  T  bandage 
and  bringing  the  thighs  firmly  together. 

Perforating  wounds  of  the  vagina  call  for  a  most  careful  examina- 
tion, for  not  only  may  the- vaginal  walls  be  involved,  but  the  rectum, 
bladder,  or  peritoneum  as  well.  Careful  suturing  is  here  the  best 
means  of  controlling  hemorrhage.  Peritonitis  may  result  from  such 
injuries  or  more  remotely,  fistulae  or  astresia  of  the  vagina. 

Any  serious  hemorrhage  following  coitus  calls  for  an  examination. 
It  may  ensue  from  a  tear  of  the  hymen,  or  of  the  posterior  wall  of 
the  vagina.  Cases  are  on  record  in  which  the  tear  penetrated  the 
rectum. 

Deep^suturing  serves  at  the  same  time  to  control  hemorrhage 
and  to  promote  repair. 


io6 


WOUNDS    OF    SPECIAL   REGIONS 


WOUNDS  OF  THE  PENIS,  SCROTUM  AND  TESTICLE 

The  penis  may  be  fractured  nearly  always  during  coitus  and  in 
the  subjects  of  a  previous  gonorrhea  which  has  produced  an  area 
of  least  resistance  in  some  of  the  peri-urethral  structures.  Usually 
the  corpus  spongiosum  is  torn. 

Immediately  the  organ  becomes  flaccid  but  within  a  few  minutes 
again  enlarges,  this  time  due  to  the  edema.  The  extra vasated  blood 
produces  at  once  the  great  discoloration  and  the  acute  flexure  which 
is  typical. 

Unless  the  extravasation  is  very  large  and  progressive,  there  is 
nothing  to  do  but  to  bandage  the  organ  and  put  the  patient  at  rest. 


Fig.   83. — B,  wound  of  testicle  repaired.     C,  Tunica  vaginalis.     A,  Beginning  its  repair. 

Otherwise  it  wil]  be  necessary  to  expose  and  suture  the  break  in 
the  corpus  cavernosum  and  this  Legueu  advises  as  likely  to  give  the 
best  functional  result.  But  with  such  a  procedure  one  may  expect 
a  severe  hemorrhage.  Open  wounds  of  the  erectile  tissues  of  the 
corpora  cavernosa  or  corpus  spongiosum  may  be  expected  to  bleed 
freely.  It  is  usually  advisable  to  pass  a  sound  to  determine  the 
integrity  of  the  urethra,  suturing  it  first,  if  involved,  and  then  care- 
fully coapting  the  erectile  tissues. 

In  the  case  of  wounds  of  the  scrotum  merely  the  integuments  may 
be  penetrated,  or  more  deeply  the  tunica  vaginalis  or  the  testicle  as 


WOUNDS    OF   THE   TESTICLE 


107 


well.  It  must  be  remembered  that  any  considerable  wounding  of 
the  tunica  of  the  testicle  may  result  in  hernia  of  the  parenchyma. 

The  scrotal  tissues  must  not  be  roughly  handled  in  cleansing,  and 
the  sutures  must  not  be  too  tight,  for  there  is  a  tendency  to  edema 
and  sloughing.  The  repair  of  these  various  structures  must  be  con- 
ducted separately. 

If  the  tunica  vaginalis  is  opened  up  and  the  testicle  herniated,  it 
must  be  carefully  cleansed  and  returned  and  the  tunica  sutured, 
with  or  without  drainage,  depending  upon  the  probabilities  of  in- 
fection.    If  the  tunica  be  destroyed,  and  the  testicle  remains  sound 


Fig.  84. — Emergency   castration.      A,   transfixion   of   the   cord  and   ligature   of  one-half. 
B,  ligature  carried  around  the  entire  cord.      iLejars.) 


it  must  be  preserved,  covering  it  as  much  as  possible  with  such  serous 
covering  as  remains.  Incised  wounds  of  the  testicle  call  for  suturing 
of  the  fibrous  coat  with  catgut. 

The  tunica  vaginalis  is  next  repaired  with  a  continuous  suture 
(Fig.  87,),  and  finally  the  scrotal  wound  is  sutured. 

If  the  testicle  is  lacerated,  or  if  seen  late  and  manifestly  infected, 
it  must  be  removed  without  delay.     Enlarge  the  wound,  exposing 


Io8  WOUNDS    OF    SPECIAL   REGIONS 

the  spermatic  cord  as  high  up  as  possible,  and  at  that  level  ligate  the 
various  elements  separately  and  firmly,  and  resect.  Trim  away  any 
infected  tissues  in  the  scrotum  and  repair,  emploving  drainage 
(Fig.  84). 

Cotton,  of  Boston  fAmer.  Jour.  Urol.,  Nov.,  1906),  describes  a 
case  of  injury  to  the  testicle  resulting  from  a  blow  on  the  scrotum  by 
a  batted  base-ball.  Shock  and  excruciating  pain  ensued,  gradu- 
ally subsiding  coincident  \N-ith  the  development  of  a  large  scrotal 
hematoma. 

Operation.  The  superficial  tissues  were  infiltrated  with  blood. 
A  rent  an  inch  long  in  the  tunica  vaginalis.  Bleeding  from  the  sper- 
matic arter^^  The  tunica  albuginea  was  torn  in  shreds,  the  paren- 
ch}Tna  destroyed.  ''The  testis  had  e\-idently  exploded  under  the 
s^sift  impact,  as  a  full  bladder  bursts  under  a  blow."'  After  removal 
of  clots  and  irrigation,  the  tissues  were  sewed  up  layer  by  layer 
with  catgut  and  without  drainage,  and  light  pressure  applied.  Con- 
valescence uneventful. 

WOUXDS  OF  THE  RECTUM 

Wounds  of  the  rectum  are  rare.  They  are  usually  punctured 
wounds  due  to  falling  upon  pointed  objects,  gunshot  wounds,  or 
tears  accompanpng  fractures  of  the  pehds.  The  chief  dangers  are 
hemorrhage  and  infection. 

Wounds  of  this  region  are  usually  self-evident,  though  their  extent 
may  be  a  matter  of  doubt,  so  that  every  such  injur}'  demands  a  care- 
ful examination.  The  examination  calls  for  inspection.  To  depend 
upon  touch  alone  may  lead  one  into  grave  error. 

In  every  serious  injury  of  this  character,  anesthetize  the  patient, 
dilate  the  anus,  and  by  the  use  of  retractors  expose  the  ivotin-d. 
Douche  ^s-ith  hot  normal  salt  solution.  If  the  hemorrhage  persists, 
the  bleeding  points  are  to  be  clamped  with  long  forceps  and  an  at- 
tempt made  to  suture  en  masse,  for  at  that  depth  it  wdU  be  hardly 
possible  to  Hgate  the  vessels.  Sometimes  in  lacerated  wounds,  the 
oozing  can  be  controlled  only  by  tamponing  the  rectum  firmly, 
packing  around  a  large  tube  in  the  center. 

Suturing  these  wounds  is  not  so  desirable  as  one  might  at  first 


WOUNDS    OF   THE   RECTUM  IO9 

think,  for  the  sutures  may  conduct  sepsis  to  the  deeper  tissues.  Do 
not  suture,  then,  unless  the  wound  is  easily  accessible,  recent  and 
clean.  If  the  sutures  are  used,  frequent  irrigations  of  normal  salt 
solution  must  be  employed  and  the  bowels  kept  quiescent  for  several 
days. 

If  the  rectal  wound  has  penetrated  the  peritoneal  cavity,  which  fact 
may  develop  in  course  of  the  examination,  or  may  be  suspected  from 
the  tympanites  and  tenderness  of  the  abdomen,  the  better  plan  is  to 
proceed  to  a  laparotomy.  A  patient  seen  recently  had  lain  for  two 
months  with  a  low  grade  of  sepsis  following  a  punctured  wound  of 
the  rectum.  He  recovered  promptly  after  a  laparotomy  exposed  and 
repaired  a  rectal  tear,  opening  into  the  pelvic  cavity. 

The  abdomen  is  to  be  opened  in  the  middle  line,  the  patient  put  in 
the  Trendelenburg  position,  the  pelvis  cleansed,  and  the  wounds  re- 
paired by  two  tiers  of  sutures. 

If  the  small  intestine  should  become  herniated  through  a  rectal 
tear,  laparotomy  is  again  indicated,  reducing  the  hernia  by  traction 
from  above.  If  the  herniated  loop  protruding  from  the  anus  be 
gangrenous,  in  order  to  avoid  infection  of  the  peritoneum  the  affected 
segment  should  be  resected  and  the  two  ends  temporarily  ligated 
before  proceeding  to  the  laparotomy.  Once  the  abdomen  is  opened, 
the  two  ends  of  the  bowel  are  to  be  pulled  up  and  anastomosed. 


CHAPTER  XI 
INJURIES  TO  THE  TRUNK 

INJURIES  TO  THE  THORAX 

Certain  elementary  notions  must  be  clearly  comprehended  and 
kept  in  mind  in  order  to  make  a  definite  diagnosis  of  these  injuries. 
These  notions  relate  to  the  anatomy,  pathology,  and  symptomatology 
of  the  thorax.  With  respect  to  the  anatomy,  one  must  keep  in  mind 
the  location  of  the  principal  vessels  of  the  chest  wall  and  mediastinum; 
the  relations  of  the  viscera  to  the  ribs;  and  the  normal  areas  of  reson- 
ance and  dullness.  In  addition,  it  is  necessary  to  recall  the  signs  and 
significance  of  the  principal  primary  complications  possible  in  any 
form  of  serious  violence  to  the  thorax,  viz. :  hemoptysis,  hemothorax, 
pneumothorax,    emphysema,   and  hemo-pericardium. 

The  various  points  of  anatomy  and  physical  diagnosis,  elementary 
though  they  be,  it  were  perhaps  better  to  enumerate  in  more  detail. 

The  principal  vessels  of  the  chest  wall  are  the  intercostals  which, 
protected  from  injury,  lie  in  the  groove  in  the  lower  border  the  rib; 
and  the  internal  mammary  i}4  inches  from  the  sternal  border,  easily 
reached  by  a  stab.  The  intercostal  may  be  compressed  in  the  man- 
ner indicated  on  page  68.  If  a  general  anesthetic  is  necessary  for 
another  purpose  the  artery  should  be  exposed  and  ligated. 

The  wounded  internal  mammary  requires  ligation  and  is  most 
easily  reached  through  the  second  or  third  intercostal  space,  lying  in 
close  contact  with  the  pleura. 

The  relations  of  the  viscera  to  the  chest  wall  acquire  a  special 
significance  in  connection  with  traumatism,  particularily  such  per- 
forating wounds  as  those  produced  by  pointed  instruments  and  the 
bullet. 

Imagine  the  track  of  the  bullet  under  a  variety  of  circumstances: 
passing  through  the  right  chest  antero-posterior,  anywhere  between 
its  apex  and  the  level  of  the  nipple  only  the  lung  will  be  injured; 

no 


HEMOTHORAX  III 

below  that  level,  the  diaphragm  and  liver  are  likely  also  to  be  per- 
forated. Outside  the  nipple  the  range  may  be  lower  and  yet  escape 
the  diaphragm  since  it  slopes  from  the  level  of  the  nipple  to  the  eighth 
rib  in  the  axillary  line. 

In  the  left  chest,  in  the  area  bounded  by  the  second  rib,  the  ster- 
num, the  sixth  rib  below  and  the  nipple  line  externally,  the  heart  or 
at  least  the  pericardium  is  likely  to  be  wounded,  and,  unless  the  track 
lies  near  the  sternal  line,  the  lung  as  well. 

Outside  the  nipple  line  and  below  its  level,  perforation  of.  the 
stomach  may  complicate  the  lung  injury. 

Passing  transversely  through  the  base  of  the  chest,  below  the  nipple 
line  we  might  expect  the  wound  to  traverse  successively  from  the 
right  side,  the  lung,  the  liver,  the  stomach,  the  spleen  and  the  lung 
again. 

The  principal  primary  complications: 

Hemoptysis,  following  an  injury  to  the  thorax,  whatever  its  nature, 
is  significant  of  one  thing — -that  the  lung  has  been  involved.  The  de- 
gree of  injury  may  be  in  a  manner  estimated  by  the  amount  of  blood 
expectorated.  In  the  dangerous  cases,  the  blood  pours  from  the 
wounded  lung  tissue  into  the  bronchus  and  gushes  from  the  mouth. 
In  other  cases,  there  is  only  a  slight  spitting  of  blood,  leading  to  the 
behef  that  the  lung  has  not  been  seriously  torn.  It  might  be  mis- 
taken for  a  hematemesis,  but  the  presence  of  rales  in  the  bronchus  of 
the  affected  side  (or  of  both)  and  the  light  color  of  the  blood  and  its 
admixture  with  air,  point  to  the  character  of  the  hemorrhage. 

Hemothorax,  an  accumulation  of  blood  in  the  pleura,  is  nearly 
always  the  result  of  injury  to  the  lung;  although,  of  course,  the  in- 
ternal mammary  artery  or  the  intercostals  may  occasionally  be  the 
source  of  the  extravasation.  Gravity  determines  where  the  blood 
will  accumulate  and  therefore  the  patient's  position  will  modify  the 
physical  signs. 

The  symptoms  and  signs  are  both  modified  by  the  quantity  of 
blood  and  the  rapidity  with  which  it  is  poured  into  the  pleural  cavity. 
In  the  slighter  forms,  there  is  scarcely  any  disturbance  of  breathing 
and  only  shght  dullness  over  the  base  of  the  lung. 

In  the  graver  forms,  the  lung  is  collapsed  and  crowded  toward  the 
hilum,  so  that  there  are  symptoms  of  asphyxia  added  to  those  of  in- 


112  INJURIES    TO    THE   TRUNK 

ternal  hemorrhage.  The  face  is  pale,  the  skin  moist  and  cold,  the 
patient  is  impelled  to  sit  up  and  gasps  for  breath,  the  pulse  is  rapid 
and  thready,  and  the  patient  may  thus  go  on  to  death.  Inspection 
reveals  a  slightly  bulging  chest  wall;  percussion,  a  complete  dull- 
ness, and  auscultation,  an  absence  of  fremitus  and  of  the  vesicular 
murmur. 

Often  there  is  an  immediate  rise  of  temperature,  due  to  absorption, 
and  which  is  to  be  distinguished  from  the  temperature  of  infection  by 
its  earlier  appearance. 

No  attempt  to  evacuate  the  extravasated  blood  is  to  be  made  in 
the  moderately  severe  cases;  in  others,  of  more  urgency,  an  aspiration 
may  give  some  temporary  relief,  tiding  the  patient  over  a  critical 
point.  Finally,  in  rare  cases,  the  magnitude  of  the  hemothorax  will 
be  such  as  to  demand  an  immediate  intervention,  with  the  purpose  in 
view  of  exposing  the  lung  and  repairing  the  wound  in  its  substance. 
Subsequently,  even  if  the  case  is  mild,  infection  may  occur  and  is  to 
be  treated  as  any  other  empyema. 

Pneiimvthorax. — Air  may  enter  the  pleural  cavity  from  without 
through  an  opening  in  the  chest  wall,  or  from  within  through  a 
rupture  in  the  lung  tissue.  In  the  first  case  it  enters  during  in- 
spiration, and  in  the  second,  during  expiration. 

The  physical  signs  and  symptoms  grow  out  of  the  pressure  within 
the  pleural  cavity  and  the  consequent  collapse  of  the  lung.  The 
chest  wall  on  the  injured  side  is  distended,  the  intercostal  spaces 
bulged  out,  the  viscera  are  displaced,  the  ribs  motionless,  the  ves- 
icular murmur  absent.  If  a  coin  laid  on  the  front  of  the  chest  is 
tapped  with  another  coin,  the  sound  will  be  heard  at  the  back.  The 
symptoms  are  principally  those  of  dyspnea. 

If  there  are  no  complications,  the  air  is  gradually  absorbed  and 
the  function  of  the  lung  restored. 

In  extreme  cases,  puncture  will  relieve  the  intrapleural  pressure; 
and  in  the  case  of  a  valvular  wound  in  the  chest  wall,  which  per- 
mits entrance  of  the  air  but  not  its  exit,  enlargement  of  the  wound 
is  indicated. 

If  air  and  blood  accumulate  simultaneously — if  a  hemo-penu- 
motJwrax  exists — the  physical  signs  -vs-iU  be  altered,  but  not  the 
symptoms. 


HERNIA   OF    THE   LUNG  II3 

Emphysema. — The  subcutaneous  cellular  tissue  may  become 
charged  with  air  and  practically  the  whole  body  be  involved.  It 
is  nearly  always  due  in  the  marked  cases  to  puncture  of  the  lung  by 
a  broken  rib.  The  air  escaping  from  the  lung  is  prevented,  by 
the  close  contact  of  the  pleural  surfaces,  from  entering  the  pleural 
cavity,  and  is  forced  into  the  loose  tissues  of  the  ruptured  chest  wall. 

In  other  rarer  cases  the  inner  aspect  of  the  lung  is  wounded,  and 
the  air  escapes  into  the  tissues  of  the  mediastinum,  and  follows  them 
up  into  the  neck. 

In  ordinary  cases  no  treatment  is  indicated  and  the  air  is  soon  ab- 
sorbed. However,  in  the  severer  forms,  the  symptoms  of  asphyxia 
and  cyanosis  may  supervene  and  then  free  incision  over  the  infiltrated 
zone  may  be  required. 

A  man  weighing  300  pounds  was  brought  into  the  City  Hospital 
with  a  crush  of  the  chest,  fracturing  several  ribs.  Within  a  half  hour 
after  the  accident  the  tissues  of  his  whole  chest  were  inflated  and  grad- 
ually the  emphysema  spread  till  his  skin  from  his  face  to  his  feet 
seemed  as  tight  as  a  drum.  His  condition  was  pitiable;  his  eyes  were 
swollen  shut,  his  features  livid,  and  his  efforts  to  breathe  distressing. 
An  effort  was  made  to  strap  his  chest;  morphin  and  atropin  in 
small  doses  were  frequently  administered,  and  the  tissues  over  the 
chest  punctured  with  numerous  small  trochars  which  were  left  in 
situ.  In  forty-eight  hours  his  pulse  and  respiration  began  to  im- 
prove and  in  a  few  days  he  was  entirely  out  of  danger. 

A  case  of  subcutaneous  and  mediastinal  emphysema  of  extreme 
gravity  was  relieved  by  incising  without  anesthesia,  the  skin  and 
fascia  above  the  clavicle  and  dissecting  the  fascias  with  finger  down 
to  the  wall  of  the  trachea.  A  suction  apparatus  was  attached  and 
the  air  escaped  in  a  continuous  stream  relieving  the  symptoms  rap- 
idly; subsequently  a  valve  drainage  of  the  pleura  was  established  to 
relieve  intrathoracic  tension  and  the  patient  made  a  smooth  recovery. 
(Amer.  Jour.  Surg.,  Oct.,  1913.) 

Hernia  of  the  lung  is  a  rare  complication,  and  may  be  immediate  or 
secondary.  In  the  first  case,  the  pulmonary  tissue  is  forced  through 
the  breach  in  the  chest  wall  by  violent  expiratory  effort.  In  some 
cases  where  the  skin  is  not  broken,  the  hernia  may  be  felt  as  a  crepi- 
tant tumor  beneath  the  skin. 
8 


114  INJURIES   TO   THE   TRUNK 

In  the  secondary  cases,  it  forms  more  slowly,  and  is  often  due  to 
the  weakening  of  the  thoracic  wall  by  inflammatory  processes. 

Hemo-pericardium. — Blood  in  the  pericardial  sac  follows  injury 
to  the  pericardium.  It  develops  more  rapidly  and,  of  course,  the 
outlook  is  much  more  grave  if  the  heart  is  also  wounded. 

The  symptoms  are  those  of  syncope  induced  by  the  compression 
of  the  heart  by  the  accumulated  fluid;  the  signs  are  those  of  increased 
cardiac  dullness.  The  apex  beat  is  lost,  the  heart  sounds  muflled,  the 
precordium  bulged.  It  is  upon  the  signs  that  one  must  depend  for 
the  diagnosis,  for  the  symptoms  are  often  complicated  by  those  of 
shock  and  by  those  which  originate  in  other  injuries  in  the  thoracic 
region. 

To  repeat,  then,  when  you  reach  the  patient  suffering  from  some 
form  of  chest  injury,  you  will  observe  the  character  of  his  respiration 
and  his  pulse;  whether  his  condition  is  immediately  serious  or  not  is 
to  be  determined  at  once  by  that  means.  If  the  circumstances  per- 
mit, you  will  proceed  to  a  systematic  examination.  Learn  from  the 
sufferer  the  location  of  his  pain  and  the  character  of  his  chief  distress. 
Note  the  appearance  of  the  sputum,  if  there  is  cough.  Inspect  the 
chest  waU  for  change  in  outUne  and  mobility  and  location  of  apex 
beat.  Determine  by  percussion  the  limits  of  the  lung  resonance  and 
heart  duUness;  and  by  auscultation,  the  presence  or  absence  of  the 
vesicular  murmur  or  of  rales. 

The  case  may  be  so  grave  that  exact  diagnosis  is  unnecessary;  or, 
again,  it  may  require  the  most  minute  examination  and  judicious 
weighing  of  the  symptoms  and  signs  to  make  a  correct  forecast  of  the 
eventualities,  and  to  formulate  a  treatment  which  will  leave  nothing 
to  regret. 

CONTUSIONS  OF  THE  CHEST 

Simple  contusions  of  the  thorax,  without  fracture  of  a  rib  or  the 
sternum  (which  are  considered  elsewhere)  and  without  symptoms 
pointing  to  internal  injury,  need  but  brief  consideration.  A  hema- 
toma is  likely  to  form.  The  pain  and  soreness  disappear  rapidly  in 
the  young,  but  are  extremely  persistent  in  the  aged  and  the  rheu- 
matic.    Strapping  and  massage  with  liniment  are  usuaUy  sufficient. 


RUPTURE   OF   THE   LUNG  II5 

On  the  other  hand,  following  simple  contusion,  there  may  be  a  de- 
gree of  shock  out  of  all  proportion  to  the  trauma. 

A  man  of  thirty,  apparently  in  good  health,  received  a  slight  blow 
"over  the  chest  in  a  friendly  scuffle.  The  blow  was  slight,  and  yet  it 
seemed  to  touch  a  vital  spot  and  made  him  gasp  for  breath.  It 
was  with  difficulty  that  he  reached  home  and  for  two  weeks  he  seemed 
upon  the  verge  of  a  penumonia.  A  month  later  he  was  still  unable 
to  work  and  an  examination  at  this  time  revealed  grave  organic  le- 
sions of  the  heart.  It  was  greatly  dilated  and  not  a  single  valve 
seemed  to  be  performing  its  function  fully.  In  spite  of  rest  and  treat- 
ment, his  condition  gradually  grew  worse,  and  in  six  months  he  died 
wdth  a  general  anasarca.  We  must  consider  that  the  heart,  as  well 
as  other  organs,  is  liable  to  contusion  and  that  from  such  injuries 
acute  endocarditis  may  result. 

In  graver  contusions,  such  as  crushing  injuries,  it  is  rupture  of  the 
lung  which  is  always  to  be  feared  and  which  is  usually  evidenced  by 
a  large  hemothorax.  It  must  always  be  remembered  that  such  an 
injury  may  occur  without  fracture  of  the  ribs  or  sternum. 

Lejars  cites  the  case  of  a  boy  eleven  years  of  age,  whose  chest  was 
run  over  by  a  wagon.  He  arose  immediately  after  the  accident,  but 
fell  again  unconscious,  with  blood  pouring  from  mouth  and  nostrils. 
This  hemorrhage  did  not  long  persist,  but  on  the  fourth  day  the  tem- 
perature rose  and  he  w^as  taken  to  the  hospital.  His  condition  was 
alarming,  the  pulse  weak  with  a  rate  of  104,  his  face  cyanosed  and 
the  dyspnea  intense;  his  heart  was  displaced  to  the  right,  and  on  the 
left  side  were  the  signs  of  marked  hemo-pneumothorax.  A  puncture 
removing  180  G.  of  the  exudate  gave  but  temporary  relief.  The 
pulse  continued  to  grow  w^eaker  and  the  dyspnea  more  intense,  and 
an  urgent  intervention  was  indicated.  The  pleura  was  opened  and 
the  lung  found  retracted  toward  the  hilum.  In  the  upper  lobe  a  tear 
was  found,  7  cm.  long,  and  running  upward,  and  backward  from  the 
cardiac  incisure.  The  wound  gaped  freely.  The  lung  was  drawn 
into  the  opening  in  the  chest  wall,  and  the  pulmonary  wound  repaired 
with  five  sutures  of  silk  which  included  considerable  tissue  to  prevent 
their  pulHng  out.  The  coaptation  was  perfected  by  a  few  superficial 
sutures.  The  upper  lobe  was  sutured  to  the  parietes  and  a  tam- 
ponade with  gauze  completed  the  operation. 


Il6  INJURIES    TO    THE    TRUNK 

The  outcome  was  unfortunate,  for  death  occurred  on  the  second 
day,  but  the  autopsy  found  the  hps  of  the  lung  wound  well  aggluti- 
nated.    There  was  no  costal  fracture. 

The  symptoms  oj  rupture  of  the  lungs  are  the  same  whether  a  rib 
be  broken  or  not:  hemo-pneumothorax,  abundant  and  increasing;  a 
spreading  emphysema;  symptoms  of  grave  anemia;  to  all  these  may 
be  added  more  or  less  quickly,  the  symptoms  of  pleural  infection. 

The  treatment,  except  in  the  cases  of  extreme  urgency,  must  be  con- 
servative and  expectant.  Shock  must  be  combated,  the  patient 
kept  absolutely  quiet,  and  the  dyspnea  relieved  by  the  sitting  posture, 
and,  if  possible,  by  inhalations  of  oxygen. 

The  anemia  can  be  relieved  by  injections  of  small  quantities  of  nor- 
mal salt  solution  frequently  repeated. 

A  puncture  will  partly  empty  the  pleural  cavity,  affording  great 
relief;  and,  eventually,  the  remaining  exudate  will  be  absorbed. 

It  may  happen  that  after  two  or  three  days  the  symptoms  will 
improve. 

But  in  the  worst  cases,  where  the  dyspnea  is  progressive  and  menac- 
ing, and  the  heart  rapidly  growing  weaker,  the  responsibility  cannot 
be  shifted.  It  is  indicated  to  operate  at  once,  to  open  up  the  thorax 
and  repair  the  tear  in  the  lung,  to  do  an  urgent  thoracotomy  (see 
page  488). 

OPEN  WOUNDS  OF  THE  THORAX 

Non-penetrating  wounds  of  the  chest  wall  are  of  sHght  significance 
and  are  to  be  treated  on  general  principles. 

Penetrating  wounds  of  the  thorax  derive  their  significance  from  the 
particular  viscera  and  vessels  which  may  happen  to  be  involved.  On 
the  clinical  basis,  then,  these  wounds  may  be  divided  into  three 
classes : 

A .  Wounds  which  involve  the  pleura  or  lung. 

B.  Wounds  which  involve  the  diaphragm. 

C.  Wounds  which  involve  the  pericardium  and  heart. 

A.    WOUNDS  OF  THE  PLEURA  AND  LUNG 

In  whatever  manner  the  wound  may  be  inflicted,  there  are  three 
elements  of  danger:  hemorrhage,  asphyxia,  and  infection.     These  are 


OPEN   WOUNDS    OF   THE   CHEST 


117 


the  factors  which  will  determine  the  line  of  treatment,  and  without 
some  urgent  indication  from  one  of  these  sources  the  treatment  must 
be  conservative.  There  are  many  things  which  stand  in  the  way  of 
radical  procedures  such  as  are  employed  in  the  case  of  abdominal 
wounds.  In  the  first  place,  the  operative  technic  is  difficult;  there  is 
a  marked  disturbance  of  respiration  following  free  access  of  air  to 
the  pleural  cavity;  the  exact  location  of  the  lung  lesion  cannot  often 
be  determined;  and,  finally,  there  is  always,  as  Lejars  remarks,  so 
much  guesswork  in  the  prognosis,  that  we  are  constrained  to  give  the 
patient  the  benefit  of  the  doubt  and  leave  the  case  to  take  its  natural 
course. 

It  is  best  to  proceed  in  this  wise:  If  the  case  is  seen  from  the  first, 
supervise  the  transportation.  Too  much  importance  cannot  be  at- 
tached to  the  dangers  of  rough  handhng.  As  has  been  said  elsewhere, 
the  nearest  shelter  is  the  best.  Cut  away  the  clothing,  scrub  the  skin 
adjacent  to  the  wound,  and  wash  out  the  wound  itself  with  alcohol  or 
sterile  salt  solution.  If,  on  opening  the  lips  of  the  wound,  a  bleeding 
point  is  seen,  catch  it  up  and  ligate. 

If  there  is  oozing  from  the  depths,  it  is  best  to  disregard  it  for  the 
present.  This  constitutes  the  primary  intervention  except  for  such 
suturing  as  may  be  required. 

Apply  a  dressing  of  sterile  gauze,  plain  or  soaked  in  collodion. 
Cover  this  with  a  layer  of  absorbent  cotton  and  apply  a  firm  bandage 
encircling  the  whole  chest.  Place  the  patient  on  his  back  with  the 
head  and  shoulders  slightly  elevated.  Absolutely  prohibit  conver- 
sation and  movement  of  any  kind;  and,  in  the  meantime,  keep  the 
patient  under  close  surveillance. 

In  general  terms,  then,  the  treatment  of  any  ordinary  open  wound 
of  the  chest  involving  the  lung  and  pleura  is  to  be  summed  up  in  two 
words,  immediate  occlusion  and  immobilization. 

But  there  are  conditions  which  demand  immediate  intervention. 
These  are  acute  anemia  or  asphyxia,  which  may  follow  hemorrhage, 
external  or  internal;  and  hernia  of  the  lung. 

External  hemorrhage  may  follow  any  extensive  wound  of  the  chest 
wall,  welling  up  from  its  depths  or  flowing  by  spurts  during  expiration. 
If  there  is  no  hemoptysis,  it  may  be  inferred  that  the  lung  is  not 
wounded;  but,  in  any  event,  the  first  treatment  must  be  directed  to- 


Il8  INJURIES    TO    THE   TRUNK 

ward  the  intercostals  and  internal  mammary.  It  may  be  that  a  tem- 
porary hemostasis  will  be  necessary,  and  the  tamponade  described  on 
page  68,  will  be  indicated. 

The  definite  hemostasis  requires  a  free  enlargement  of  the  wound. 
If  pressure  made  against  the  lower  border  of  the  rib  by  an  aseptic 
finger  introduced  through  the  enlarged  wound  causes  cessation  of 
hemorrhage,  it  is  certain  that  it  is  an  intercostal  artery  that  is  at 
fault.  It  may  be  difficult  to  clamp;  it  may  be  necessary  to  resect  a 
rib,  or  to  detach  the  periosteum,  which  will  carry  the  artery  with  it. 
A  curved  needle  threaded  with  catgut  is  then  carried  around  the 
artery.  The  ligature  is  tied  and  the  hemorrhage  thus  controlled. 
The  internal  mammary  may  require  ligation  above  and  below  the 
wound. 

Internal  hemorrhage  is  in  every  way  more  serious,  for  to  the  anemia 
is  added  the  asphyxia  which  follows  the  compression  of  the  lung. 

The  patient  is  pale,  anxious,  with  cold  extremities,  weak  pulse,  and 
sighing  respiration,  the  chest  wall  bulges;  the  normal  resonance  and 
vesicular  murmur  are  altered;  in  short,  there  are  all  the  signs  and 
symptoms  of  an  increasing  hemothorax  or  hemo-pneumothorax. 

But  even  in  the  presence  of  these  grave  symptoms,  it  is  by  no  means 
always  indicated  to  operate.  One  must  be  content  to  repair  the 
wound,  occlude  and  immobilize,  and  wait  awhile. 

But  when  the  wound  is  followed  by  an  immediate  and  complete 
hemothorax,  or  when  the  symptoms  and  signs  point  to  a  rapidly  ap- 
proaching fatality,  one  must  stand  by  with  folded  hands  and  see  the 
end  come^  or  operate;  for  there  is  nothing  else  of  any  use.  An  urgent 
thoracotomy  must  be  done. 

Hernia  of  the  lung  is  rare.  The  tumor  is  of  variable  size  and  is  at 
first  crepitant,  but  rapidly  darkens  and  becomes  hepatized. 

The  indications  for  treatment  depend  upon  the  time  which  has 
elapsed  and  upon  the  condition  of  the  tumor.  If  the  wound  is  recent 
and  the  lung  intact,  the  hernia  must  be  reduced.  Begin  by  a  careful 
disinfection  of  the  wound.  Cover  the  tumor  with  an  aseptic  com- 
press and  tuck  its  edges  under  the  whole  circumference  of  the  wound. 
A  steady  pressure  over  the  central  portion  of  the  tumor  will  expel  the 
air  little  by  little;  and,  by  reducing  its  volume,  favor  the  reduction  of 
the  tumor. 


OPEN   WOUNDS    OF   THE   CHEST  II9 

The  compress  is  to  be  left  until  the  skin  wound  is  partially  sutured, 
since  by  that  means  one  may  prevent  the  sudden  pneumothorax 
which  sometimes  follows  reduction. 

If  the  lung  has  been  wounded,  it  must  be  repaired  by  suture,  or  by 
ligation  and  resection  before  being  reduced. 

If  some  time  has  elapsed^  it  is  as  unsafe  to  reduce  it  as  to  reduce  a 
doubtful  herniated  gut. 

Lejars  insists  upon  resection  with  the  thermocautery.  Around  the 
base  of  the  tumor  pass  a  ligature  threaded  on  a  blunt  needle.  By 
tying  the  ligature,  a  pedicle  is  formed  which  is  to  be  amputated  with 
the  thermocautery.  The  stump  is  carefully  disinfected  and  reduced, 
the  chest  wall  repaired,  and  drainage  instituted. 

Finally,  in  the  case  where  the  tumor  is  already  gangrenous  and 
sloughing,  it  is  necessary  to  limit  the  treatment  to  antisepsis,  leaving 
the  slough  to  detach  itself,  and  happily  a  cure  may  follow  such  spon- 
taneous amputation. 

Axtell  reports  a  case  of  open  wound  of  the  chest  which  illustrates 
what  the  doctor's  patience  arid  nature's  efforts  may  accomplish  in 
conditions  apparently  most  desperate.  (American  Jour.  Surg., 
Feb.,  1909). 

A  shingle  sawyer  of  twenty-eight,  robust  and  muscular,  fell  against 
a  great  circular  saw  revolving  many  thousand  times  per  minute. 
Sections  of  the  second,  third,  fourth,  fifth  and  sixth  ribs  were  cut 
away,  these  segments  varying  in  length  from  i  inch  at  the  second  to 
3  inches  at  the  fourth  and  fifth  ribs.  The  costal  pleura  was  com- 
pletely destroyed  over  the  seat  of  the  greatest  injury.  The  lung  and 
pericardium  were  exposed.  There  was  one  puncture  of  the  lung 
from  which  the  air  bubbled  and  emphysema  followed.  All  the  inter- 
costal arteries,  veins,  and  nerves  in  the  injured  area  were  severed. 
The  pectoralis  major  was  completely  separated  from  the  chest,  and  a 
part  of  the  pectoralis  minor.  The  wounded  man,  thrown  from  the 
saw,  fell  face  downward  into  a  dust  pile  and  the  whole  exposed  sur- 
face of  the  wound  was  filled  with  sawdust  and  grease. 

He  was  carried  to  the  hospital  and  attempt  made  to  repair  the 
damage.  "Over  450  spiculae  of  wood  fiber  were  picked  out  piece  by 
piece  from  the  chest  cavity  and  the  surface  of  the  lung.  Several 
large  lumps  of  greasy  dust  were  removed  from  the  depths  of  the  chest 


I20  INJURIES    TO   THE   TRUNK 

cavity."  All  the  ragged  edges  of  the  costal  pleura,  skin,  and  muscles 
were  trimmed  away.  The  jagged  and  uneven  ends  of  the  severed 
ribs  were  cut  off  smooth  in  order  to  bring  the  periosteum  over  them. 
To  take  the  place  of  the  costal  pleura  destroyed,  a  flap  was  stripped 
off  the  pectoralis  major  from  near  its  attachment  to  the  humerus; 
left  attached  near  the  free  end  of  the  divided  muscle,  it  was  turned 
forward  toward  the  sternum  and  sutured  to  its  margin,  to  the  inter- 
costal muscles,  and  the  periosteum  of  the  stumps  of  the  ribs.  The 
severed  muscles  were  drawn  together  by  cable  sutures  and  the  skin 
flap  drawn  into  place  and  incompletely  sutured.  Ample  drainage 
was  installed.  The  intervention  consumed  several  hours,  something 
hke  1 80  sutures  and  ligatures  being  required.  The  emphysema  was 
enormous  at  first,  extending  from  the  scalp  to  the  knees,  but 
disappeared  after  forty-eight  hours.  At  the  end  of  six  weeks  the 
patient  had  practically  recovered  without  adhesions  or  restriction  of 
the  lung. 

B.    WOUNDS  AT  THE  BASE  OF  THE  THORAX 

Wounds  at  the  base  of  the  thorax  require  a  separate  consideration, 
for  the  reason  that  both  the  thoracic  and  abdominal  cavities  may  be 
involved  through  wounds  of  the  diaphragm. 

It  must  be  remembered  that  the  diaphragm  corresponds  to  the  level 
of  the  fifth  rib  in  the  right  nipple  line,  and  to  the  level  of  the  sixth  rib 
in  the  left. 

In  stab  or  gunshot  wounds,  the  lung  on  the  one  hand,  and  the 
stomach,  intestine,  spleen,  and  liver  on  the  other,  may  be  wounded 
simultaneously;  so  that,  compared  with  the  thoracic  wounds  just 
considered,  those  at  the  base  are  much  more  complicated  with  respect 
to  prognosis,  diagnosis,  and  treatment. 

These  wounds  at  the  base  of  the  thorax  involving  the  diaphragm, 
will  nearly  always  present  an  omental  hernia.  It  is  often  necessary, 
after  enlarging  the  thoracic  wound  by  resecting  a  rib  or  forming  a 
costal  flap,  to  resect  the  protruding  omentum;  and,  at  the  moment  of 
reduction  of  the  stump,  one  may  have  an  unobstructed  view  of  the 
wound  in  the  diaphragm.  If  blood  oozes  from  it,  there  is  abundant 
evidence  of  a  wound  of  an  abdominal  viscus.  If  there  is  no  bleeding, 
introduce  a  finger  through  the  opening  in  the  diaphragm  and  examine 


WOUNDS   AT   THE   BASE    OF   THE   THOR^VX  121 

the  stomach  and  adjacent  structures.  If  no  injury  is  found,  and  the 
examining  finger  is  not  covered  with  blood,  proceed  at  once  to  repair 
the  diaphragm. 

A  curved  needle  is  best,  and  interrupted  sutures.  If  there  are 
wounds  of  the  abdominal  viscera,  they  may  possibly  be  repaired 
through  the  phrenic  wound;  and,  in  fact,  if  at  all  possible,  it  is  the 
method  of  election.  By  this  route  one  may  readily  reach  the  convex 
surface  of  the  liver  on  the  right  side,  or  on  the  left  the  greater  curva- 
ture of  stomach. 

Still,  if  the  exploration  is  difficult,  if  the  bleeding  is  abundant,  it  is 
better  to  lose  no  time,  but  to  do  a  median  laparotomy  at  once,  gaining 
additional  room,  if  necessary,  by  a  transverse  incision,  following  the 
costal  arch.  Subsequently  the  wound  in  the  diaphragm  may  be  re- 
paired through  the  thoracic  opening. 

Ludlow,  of  Cleveland  (Annals  of  Surgery,  June,  1905),  reports  a 
case  which  illustrates  this  subject  and  exemplifiies  the  treatment  in 
general. 

The  patient  had  received  two  stab  wounds  in  the  left  side,  inflicted 
with  a  candy  maker's  knife  which  had  two  blades  set  in  a  hea\y 
handle.  One  wound  entered  at  the  ninth  interspace  in  the  axillary 
line,  and  through  it  protruded  omentum.  The  blade  had  entered  the 
chest  wall  obliquely  and  the  skin  acted  as  a  valve;  but,  when  the 
skin  was  retracted,  the  air  rushed  in  and  out  of  the  pleural  cavity  with 
each  respiration.     The  hemorrhage  from  the  wound  was  slight. 

The  second  wound  was  situated  directly  below  the  first  in  the  elev- 
enth interpsace.  Omentum  protruded  from  this  wound  also,  and  the 
bleeding  was  slow,  but  apparently  increasing. 

Operation. — Ether  anesthesia;  a  careful  cleansing  of  the  field.  A 
digital  examination  revealed  the  fact  that  the  upper  wound,  travers- 
ing the  pleural  cavity  without  injury  to  the  lung,  had  perforated  the 
diaphragm.  The  finger  passed  through  these  wounds,  met  the  finger 
of  the  other  hand  passed  through  the  lower  wound,  in  the  abdominal 
cavity. 

The  lower  wound  was  enlarged,  revealing  an  active  hemorrhage 
from  the  spleen.  The  cut  surface  of  the  spleen  was  pulled  into  the 
wound  and  a  spurting  artery  clamped.     The  splenic  wound  was 


122  INJURIES    TO   THE   TRUNK 

4  cm.  in  length  and  extended  almost  through  the  substance  of  the 
organ. 

The  cut  surfaces  were  brought  into  apposition  by  mattress  sutures 
of  plain  catgut  No.  2,  on  a  curved  round  needle.  This  controlled 
the  hemorrhage.  Neither  by  palpation  or  inspection  could  any 
wound  of  the  stomach  or  intestines  be  found.  The  diaphragm  was 
then  repaired  with  chromic  gut  No.  3.  The  operation  was  accom- 
plished without  the  resection  of  a  rib.  A  small  cigarette  drain  was 
left  in  both  wounds  and  the  external  wounds  sutured.  The  week 
following  the  operation  there  was  some  discharge  of  blood  and  de- 
bris, but  no  active  hemorrhage.  The  recovery  was  uneventful  and 
complete. 

Wounds  of  the  diaphragm  of  whatever  form,  perforations,  or  rup- 
tures due  to  crushing  injuries  to  the  chest,  are  likely  to  be  the  site  of 
herniae. 

Especially  in  the  latter  class  of  injuries,  must  one  be  on  his  guard 
for  this  injury.  Sometimes  there  are  certain  signs  which  point  at 
once  to  the  presence  of  a  diaphragmatic  hernia;  the  displacement  of 
the  heart,  the  bulging  of  the  lower  intercostal  spaces,  and  the  presence 
on  auscultation  of  sounds  which  in  no  way  resemble  the  vesicular 
murmur.  In  these  cases,  it  is  best  to  open  up  the  eighth  intercostal 
space  and  resect  the  ninth  rib,  which  will  usually  give  a  free  access  to 
the  site  of  injury. 

C.    WOUNDS  OF  THE  PERICARDIUM  AND  HEART 

Not  every  precordial  wound  will  reach  the  heart.  Such  a  wound 
may  be  followed  only  by  a  slight  emphysema  and  is  to  be  treated  by 
aseptic  occlusion. 

If  the  wound  has  actually  penetrated  to  the  heart,  death  is  usually 
so  rapid  that  no  measure  or  relief  can  be  considered.  If  it  is  a  gun- 
shot wound,  death  results  from  shock  and  hemorrhage;  if  it  is  a  stab 
or  punctured  wound,  shock  plays  a  very  minor  part.  It  is  not  very 
likely  that  any  small  size  stab  wound  of  the  heart  interferes  at  once 
seriously  with  the  heart's  action,  unless  it  involves  the  ''coordination 
center,"  which,  it  is  claimed^  lies  in  the  upper  third  of  the  inter-ven- 
tricular groove. 

If  the  wound  in  the  pericardium  be  small  or  valve-like,  the  blood  is 


WOUNDS    OF   THE   HEART  1 23 

retained  within  the  cavity  and  the  constantly  increasing  intra-peri- 
cardial  pressure  effects  the  softer  and  more  yielding  of  the  structures 
within  the  sac — viz.,  the  pulmonary  veins  and  the  descending  vena 
cava  and  the  auricles;  in  this  manner,  the  venous  current  to  the 
auricles  is  cut  off  and  the  agitated  heart  works  to  no  purpose.  The 
sense  of  oppression,  the  cyanosis,  and  venous  engorgement  all  bear 
witness  to  the  compression  of  the  auricles.  In  the  meantime,  the 
pulse  grows  miserably  weak  and  rapid;  the  apex  beat  is  lost,  the  heart 
sounds  are  muffled,  the  pericardial  dullness  is  augmented,  and  the 
thoracic  wall  bulged.  In  this  manner  from  ''heart  tamponade," 
death  soon  ensues.  If  the  wound  in  the  pericardium  is  large  and  the 
pleura  opened,  the  hemorrhage  rapidly  fills  the  pleura  producing 
hemothorax,  scarcely  less  distressing  than  the  hemo-pericardium. 

If  the  opening  in  the  thoracic  wall  is  free,  the  hemorrhage  is  ex- 
ternal; the  blood  spurts  from  the  wound  or  wells  up  continuously,  un- 
controlled by  pressure  or  occlusion,  and  death  ensues  from  hemor- 
rhage, simply. 

In  spite  of  all  this,  however,  a  wound  of  the  heart  is  not  to  be  con- 
sidered as  inevitably  fatal  and  beyond  surgical  skill.  The  number  of 
reported  cases  saved  by  timely  intervention  is  constantly  increasing 
and  will  increase  all  the  more  rapidly  as  time  goes  by.  Any  wound  of 
the  heart  sufficiently  large  to  produce  hemorrhage,  whether  external 
or  internal,  is  potentially  fatal. 

The  only  measure  of  relief  is  operation.  The  pericardium  is  to 
be  exposed  and  opened,  the  heart  relieved  of  pressure,  and  the  wound 
repaired. 

The  question  arises  as  to  how  late  an  operation  may  be  undertaken, 
but  this  cannot  be  answered  by  a  general  formula;  as  long  as  there 
is  life,  there  is  hope  in  skillful  intervention.  In  the  cases  reported, 
the  great  majority  were  operated  not  later  than  six  hours  after  the 
injury. 

Regarding  the  location  of  the  wound  in  the  heart,  the  right  and 
left  sides  are  injured  with  equal  frequency,  but  the  ventricles  are  in 
much  greater  danger  than  the  auricle  in  the  proportion  of  seventeen 
to  one  (Vaughn).  The  external  wound  may  be  located  over  any 
intercostal  space,  but  the  great  majority  will  be  found  in  the  fourth, 
fifth,  and  third  in  order  of  frequency. 


124  INJURIES    TO    THE    TRUNK 

Vaughn,  who  has  carefully  studied  the  statistics  of  operations  for 
these  injuries,  and  who  reports  his  second  successful  case  of  suture  of 
the  heart  '].  A.  M.  A..  Feb.  6,  1909 J,  offers  the  follo\s'ing  conclusions: 
that  there  is  no  longer  any  question  as  to  the  propriety  of  the  opera- 
tion, but  that  its  mortality  is  probably  the  same  as  it  was  twelve 
years  ago  when  the  operation  was  first  introduced.  Probably  httle 
more  can  be  done  to  prevent  death  from  hemorrhage,  but  the  pre- 
vention of  the  great  cause  of  death  follo-w^ng  the  operation,  infection 
of  the  pericardium,  remains  a  surgical  problem  yet  to  be  solved. 
The  principles  of  asepsis  and  drainage  as  applied  to  the  operation,  are 
yet  to  be  more  carefully  worked  out. 

This  summary  still  holds  good  at  this  later  date  except  that  there 
is  disposition  to  extend  the  indications  for  operation  to  those  cases 
in  which  the  nature  of  the  wound  presupposes  heart  injury  but  in 
which  the  classical  symptoms  have  not  yet  developed.  For  it  is 
certain  that  heart  "tamponnade"  with  its  concomitant  clinical  pic- 
ture is  often  delayed. 

An  example  is  in  mind. 

A  negro  was  brought  to  the  City  Hospital  with  a  stab  wound  in  the 
fourth  intercostal  space  about  halfway  between  the  sternal  border 
and  the  nipple  Une.  His  condition  was  good  except  that  he  had  oc- 
casional sUght  attacks  of  dyspnea;  pulse  100,  respiration  24.  In  the 
course  of  two  or  three  hours  his  symptoms  had  slightly  but  percepti- 
bly grown  worse.  He  refused  operation.  From  that  time,  hour  by 
hour  the  heart  dullness  increased,  the  heart  sounds  altered,  the 
radial  pulse  weakened  the  dyspnea  became  more  distressing  and 
finally  after  thirty  hours  he  died. 

The  autopsy  revealed  a  small  wound  of  the  right  ventricle.  The 
only  hemorrhage  was  within  the  pericardial  sac. 

An  operation  at  the  time  of  admission  or  a  few  hours  thereafter 
would  have  been  performed  under  Ytry  favorable  circumstances  and 
almost  certainly  would  have  saved  the  man's  life. 

On  the  other  side,  Wagner  reports  a  stab  case  presenting  all  the 
signs  of  injur}-  to  the  heart  which  an  operation  proved  to  be  intact, 
although  blood  had  accumulated  -^-ithin  and  around  the  pericardium. 
The  man  would  undoubtedlv  have  recovered  \sdthout  operation  but 


CONTUSIONS    OF   THE   ABDOMEN  1 25 

the  case  would  have  gone  on  record  as  one  recovering  from  stab  of 
heart  under  conservative  treatment. 

Arx  reports  a  case  in  which  the  pain  and  physical  signs  pointed  to 
injury  to  the  diaphragm  and  liver,  but  a  laparotomy  proved  them 
to  be  intact.  The  heart  was  exposed,  revealing  a  hole  in  the  right 
ventricle  far  under  the  sternum.  When  the  pericardium  was  opened 
and  the  clots  released  the  heart  improved  at  once.  In  this  case  the 
heart  wound  was  not  sutured  but  was  covered  with  a  strip  of  gauze 
which  was  brought  out  through  the  closely  sutured  wound.  The 
pulse  kept  between  80  and  88  and  the  temperature  remained  normal. 
Arx  remarks  that  this  case  emphasizes  the  value  of  proper  drainage 
(J.  A.  M.  A.,  Aug.,  1913). 

A  number  of  cases  of  needle  punctures  of  the  heart  have  been 
reported.  About  60  per  cent,  die,  the  result  of  intra-pericardial 
hemorrhage  occurring  within  ten  days  of  the  accident. 

INJURIES  TO  THE  ABDOMEN 

I.  Contusions.     II.  Wounds. 

I.  Contusions  of  the  abdomen  occur  in  many  ways;  they  may  be 
the  result  of  severe  blows,  the  kick  of  a  horse,  from  falls,  or  from  the 
crush  of  heavy  wheels  of  vehicles.  The  gravity  of  such  an  injury  is 
proportionate  to  the  amount  of  visceral  injury,  but  this  is  often  not 
apparent  from  the  first. 

Whether  the  viscera  are  injured  or  not,  there  is  always  some  degree 
of  shock.  In  the  first  hours  following  the  injury,  in  the  doubtful 
cases,  the  therapeusis  must  be  Umited  to  the  treatment  of  shock. 
If  transportation  is  necessary,  it  must  be  done  with  the  greatest  care. 

Once  the  patient  is  placed  in  bed,  his  clothing  must  be  removed, 
his  head  lowered,  the  extremities  kept  warm,  and  repeated  injections 
of  normal  salt  solution  or  adrenalin  made,  as  the  character  of  the 
shock  indicates. 

In  the  meantime,  the  case  is  to  be  studied  and  it  is  to  be  decided 
whether  or  not  there  is  a  rupture  of  an  organ,  or  other  source  of  hem- 
orrhage. 

The  responsibiUty  is  a  heavy  one,  for  an  internal  injury  overlooked 
or  discovered  too  late,  is  likely  to  result  in  death.     The  patient  may 


126  IXJCiaES    TO    THE    TRUXK 

rapidly  recover  from  the  shock,  but  this  by  no  means  proves  the 
absence  of  a  visceral  hurt. 

In  the  tA-pical  case  of  grave  injury,  the  symptoms  of  shock  are  only 
temporarily  reheved  by  the  injections;  rather,  they  are  shortly  re- 
placed by  those  of  internal  hemorrhage.  The  pulse  remains  small 
and  frequent,  the  skin  cold,  the  face  anxious  and  dra-^Ti.  The  abdo- 
men is  distended,  and  tender  to  the  least  pressure,  especially  in  the 
zone  of  direct  injur}-.  There  may  be  dullness  in  the  flanks.  There  is 
no  escape  of  gas  from  the  bowels,  or  passage  of  urine.  The  patient 
is  restless  and  frequently  sighs,  and  seems  to  realize  his  impending 
fate. 

In  such  a  case,  the  indications  are  plain.  There  can  be  no  excuse 
for  delay,  for  awaiting  the  signs  that  can  only  be  those  of  beginning 
peritonitis.     Prepare  for  an  immediate  laparotomy. 

But  suppose  the  case  is  not  accompanied  by  the  t>^ical  sjnnptoms. 
How  shall  we  determine  in  two  or  three  hours  whether  or  not  there  is 
a  grave  lesion?  A  conclusion  must  be  reached  from  the  study  of  two 
factors:  (a)  the  pulse,  and  (b)  abdominal  tension. 

{a.)  The  pulse,  disturbed  at  first  by  the  shock,  rapidly  approaches 
the  normal  perhaps,  but  ^sithin  a  haH  hour  or  sooner,  it  can  be  deter- 
mined that  it  is  getting  weaker  and  more  rapid.  Such  a  change  is 
particularly  indicative  of  hemorrhage.  If  there  is  any  discrepancy 
between  the  pulse  and  temperature,  Lejars  insists  that  the  former  is 
the  safer  guide,  for  a  subnormal  temperature  resulting  from  shock 
may  persist  long  after  the  other  symptoms  have  disappeared. 

(b)  The  abdomen  may  or  may  not  be  swollen,  but  over  the  site  of 
the  injur}'  the  abdominal  muscles  soon  begin  to  grow  rigid,  and  resent 
the  least  touch,  under  which  they  may  be  felt  to  contract  and  stiffen. 
This  rigidity,  localized  at  first,  tends  to  spread  and  include  the  entire 
abdomen. 

The  tension  is  usually  augmented  by  progressive  meteorism,  which 
is  also  at  first  localized,  but  rapidly  becomes  general. 

Dullness  in  the  flanks  is  a  valuable  sign  when  present,  but  its 
absence  settles  nothing.  It  mav  be  masked  bv  the  distended  stom- 
ach  and  intestine;  again  the  blood  may  not  collect  in  the  ihac  fossa, 
but  may  flow  directly  into  the  pelvic  caN-ity,  especially  if  the  hemor- 
rhage is  on  the  left  side  of  the  mesentery. 


RUPTURE    OF   THE   INTESTINE  1 27 

These  modifications  of  pulse  and  temperature,  of  abdominal  tender- 
ness and  tension,  must  be  taken  as  sufficient  indication  for  urgent  in- 
tervention; for  the  prognosis  does  not,  in  reality,  depend  more  upon 
the  nature  and  multiplicity  of  the  visceral  lesions  than  upon  the  time 
of  intervention,  for  every  hour  of  delay  adds  to  the  chances  of  infec- 
tion and  sepsis — elements  which  the  early  operation  may  practically 
eliminate. 

Another  eventuahty:  The  case  is  not  seen  until  infection  has  fixed 
itself  upon  the  peritoneum;  the  pulse  is  weak  and  rapid  and  progress- 
ively growing  worse;  the  temperature  is  subnormal,  the  extremities 
cold;  a  marked  tympanites,  with  persistent  vomiting,  perhaps  comes 
on. 

Then,  indeed,  it  is  late  to  operate — especially  when  that  means  a 
long  and  tedious  laparotomy.  Every  doctor  must  answer  for  him- 
self the  question,''  Is  it  too  late?^'  As  Lejars  says,  we  must  extend  as 
far  as  possible  the  limits  of  intervention  in  such  cases,  for  it  is  the  last 
resource;  and,  even  though  the  mortality  is  very  great,  the  occasional 
unexpected  recovery  legitimizes  the  operation. 

Who  has  not  had  his  sad  experiences  with  these  cases?  A  single 
example  illustrates  the  subject  of  intestinal  rupture.  A  laborer  roll- 
ing a  log  off  a  wagon  was  struck  \'iolently  in  the  abdomen  by  the  end 
of  his  lever  caught  by  the  log  as  it  fell. 

He  was  unconscious  for  a  moment  then  arose,  vomited  once  and 
after  a  little  rest  to  get  his  breath  resumed  his  labor. 

After  an  hour  or  so,  however,  he  decided  he  had  better  go  home 
as  he  began  to  feel  some  pain  in  the  right  iliac  region  where  the  blow 
had  fallen;  six  or  eight  hours  later  he  called  his  doctor  who  could 
find  no  definite  indication  of  any  serious  lesion,  though  the  pain  had 
grown  very  severe. 

The  next  morning  twenty-four  hours  later  there  was  some  rigidity, 
some  tympanites,  an  increase  in  the  pulse  rate,  temperature  loi, 
complete  constipation. 

I  saw  him  some  sixty  hours  after  the  accident.  His  aspect  was  typ- 
ical of  peritonitis.  He  was  vomiting  bile  with  a  fecal  odor.  He  was 
quite  conscious  and  expressed  the  opinion  that  he  was  done  for  unless 
surgery  held  out  some  hope. 

He  lived  far  out  in  the  country  and  it  was  manifest  that  he  would 


128  IN'jrTRIES    TO    THE    TRUNK 

not  live  through  the  journey  to  a  hospital.  His  kitchen  was  hurriedly 
converted  into  an  operating  room  and  a  laparotomy  performed.  It 
revealed  two  small  circular  openings  in  the  ileum  close  to  the  cecal 
end,  a  small  quantity  of  the  intestinal  content  free  in  the  cavity  anb 
a   general   peritonitis. 

The  whole  operation  did  not  last  forty  minutes  but  the  poor  man 
died  four  hours  later. 

It  was  apparent  that  he  had  suffered  a  contusion  of  the  bowel  and 
that  subsequently  the  two  small  sloughs  had  occurred  and  this  se- 
quence accounted  for  the  absence  of  hemorrhage  and  the  small 
escape  of  intestinal  fluids. 

Maurice  Kahn  emphasizes  the  necessity  of  early  diagnosis  of  in- 
testinal rupture  and  discusses  in  detail  the  aids  thereto;  the  part 
which  each  symptom  and  sign  should  have  in  this  determination: 
Shock,  pain,  tenderness,  rigidity,  vomiting,  circulation,  respiration, 
temperature,  facial  expression,  loss  of  liver  dullness.  He  concludes 
that  if  we  have  the  persistence  for  a  few  hours  of  the  initial  symptoms, 
especially  of  rigidity  and  pain  we  are  justified  even  in  the  absence  of 
other  symptoms  in  urging  an  exploratory  operation.  (J.  A.  M.  A., 
March  7,  1914.) 

Rupture  of  the  liver  in  addition  to  the  indications  already  discussed 
may  have  some  special  features. 

In  the  first  place  whatever  shock  there  may  be  is  early  displaced 
by  symptoms  of  hemorrhage. 

The  pulse  may  be  abnormally  slow  by  reason  of  bile  absorption;  and 
the  pain  is  definitely  localized  in  the  right  hypochondrium. 

Much  more  frequently  the  tear  involves  the  right  lobe. 

Rupture  of  the  spleen  produces  neither  the  shock,  the  abdominal 
tension,  nor  the  early  peritonitis  which  follow  rupture  of  the  other 
viscera.  Hemorrhage  is  the  main  feature  and  the  severity  of  the 
symptoms  are  in  proportion  to  the  loss  of  blood  and  usually  this  de- 
pends upon  the  extent  of  the  laceration.  However,  even  a  small  cut 
at  the  hilum  might  produce  early  and  urgent  symptoms.  (See 
also   laparotomy   for    traumatism.) 

II.  Wounds  of  the  Ahdomen}^C\\mcdX\y,  these  fall  into  two  groups, 
(a)  those  in  which  there  is  doubtful  perforation  of  the  peritoneum, 

^For  gunshot  wounds,  see  pages  151  and    192. 


STAB    WOUND   OF   ABDOMEN 


129 


and  (b)  those  in  which  perforation  of  the  peritoneum  is  quite 
obvious. 

(a)  The  patient  presents  himself  with  a  wound  of  the  abdominal 
parietes,  of  doubtful  depth.  It  is  easy  to  determine,  once  for  all, 
whether  the  peritoneum  has  been  perforated  (and  upon  that  the 
prognosis  depends)  by  passing  a  probe  or  grooved  director.  But  one 
should  certainly  do  nothing  of  the  kind.  There  is  a  definite  mode  of 
examination  to  which  one  must  rigidly  adhere. 

Begin  by  a  hurried  inquiry  into  the  circumstances  of  the  injury, 
and  the  character  of  the  weapon.  Disinfect  the  hands  for  an  opera- 
tion. Finally  scrub  and  disinfect  the  abdominal  walls.  Not  until 
this  is  completed,  is  the  wound  ready  to  be  examined. 

Carefully  separate  the  lips  of  the  wound  with  finger  or  retractors; 
and,  as  you  proceed,  carefully  wape  each  layer  as  it  is  exposed.  If 
necessary  to  facilitate  inspection,  enlarge  the  wound;  this  will  often 
be  the  case,  especially  where  the  vulnerating  instrument  has  entered 
obliquely. 

Dividing  the  various  layers,  the  peritoneum  is  reached  and  found 
intact;  there  is  no  oozing  from  below  the  level  of  the  muscular  layers, 
and,  if  this  finding  accords  with  the  other  signs  observed,  you  may 
conclude  at  once  that  the  wound  is  non- penetrating.  In  such  a  case, 
carefully  cleanse  the  wound  and  repair  each  layer  separately  by  con- 
tinuous suture  with  catgut;  the  skin  with  silk  or  silkworm-gut; 
cover  with  sterile  gauze,  a  thick  layer  of  absorbent  cotton,  and  a 
firm  abdominal  binder;  and  thus  have  been  taken  the  best  steps 
to  prevent  infection  or  ventral  hernia,  which  is  often  the  result  of 
these  wounds. 

If  the  wound  is  penetrating^  the  mode  of  procedure  depends  upon 
whether  it  is  (a)  a  narrow,  or  (b)  a  large  incised  wound. 

(a)  A  stah  wound  is  the  type — -a  thrust  from  a  knife,  dagger,  or 
bayonet.  There  may  be  persistent  oozing  of  blood  alone,  or  blood 
mixed  with  bile  and  urine,  or  ''food  products."  Such  a  mixture  is 
pathognomonic  of  visceral  injury,  but  nothing  can  be  decided  from 
its  absence. 

The  persistent  hemorrhage  is  strongly  suggestive  of  serious  injury 
to  an  organ,  especially  where  it  coexists  with  a  fading  pulse,  pallor, 
tympanites,  and  rigidity  and  tenderness  of  the  belly  wall;  yet  the  ab- 
9 


130  INJURIES    TO   THE   TRUNK 

sence  of  all  these  signs  gives  no  assurance  of  the  absence  of  a  visceral 
injury. 

In  any  event,  then,  an  explarotory  laparotomy  is  indicated;  for  only 
by  that  means  can  one  assure  himself  of  the  conditions.  Ordinarily, 
the  wound  itself  is  enlarged  for  the  purpose  of  exploration,  but  in  the 
case  of  more  than  one  wound,  or  when  the  abdominal  walls  are  very 
thick,  it  may  be  advantageous  to  resort  at  once  to  median  laparotomy. 
In  either  case,  the  abdominal  opening  should  be  large  enough  for 
rapid  work.  If  the  laparotomy  is  done  at  the  site  of  the  injury,  it 
will  be  wise  to  disarrange  the  viscera  as  little  as  possible,  when  spong- 
ing out  the  exudates.  Carefully  inspect  whatever  parts  present,  and 
often  the  lesion  will  be  revealed  by  this  first  search. 

If  a  median  laparotomy  is  done,  as  soon  as  the  cavity  is  opened 
proceed  to  the  site  of  the  injury;  cover  the  adjacent  coils  of  intestine 
with  compresses,  thus  preventing  their  possible  infection. 

The  lesions  are  only  rarely  multiple  or  difficult  of  repair  in  this  class 
of  abdominal  injuries. 

(b)  Extensive  Incised  Wounds. — ^These  wounds  are  produced  by  in- 
struments with  a  long  cutting  edge,  or  by  the. ripping  cut  of  small 
knives.     Horned  animals  occasionally  produce  them. 

The  chief  characteristic  of  these  wounds  is  eventration,  always 
present  in  some  degree.  If  the  case  is  seen  immediately,  the  mode  of 
procedure  is  very  definite.  But  only  too  often  the  patient's  efforts 
have  augmented  the  hernia,  or  he  or  his  friends  have  made  untimely 
attempts  to  reduce  it. 

Having  cleansed  the  hands  and  the  abdominal  walls  in  the  usual 
way,  begin  next  a  systematic  cleansing  of  the  eventrated  mass. 
Cleanse  it  with  warm  sterile  water,  or  normal  salt  solution,  rubbing 
gently  with  the  fingers,  every  inch  of  the  projecting  bowel  or  omen- 
tum. Only  in  the  thoroughness  of  this  step  is  there  any  assurance 
of  success.  If  any  visceral  wounds  are  discovered  in  the  cleansing 
process,  they  are  to  be  repaired  at  this  time. 

Once  the  cleansing  and  repair  are  complete,  proceed  to  reduce  the 
hernia.  The  wound  may  need  to  be  enlarged;  if  this  is  necessary, 
sHp  a  finger  under  an  angle  of  the  wound  to  serve  as  a  guide,  and  di- 
vide the  tissues  with  scissors.  The  other  angle  may  be  treated  in  the 
same  way.     Catch  up  the  peritoneum  with  forceps  along  the  whole 


STAB    WOUND   OF   ABDOMEN  I3I 

length  of  each  side  of  the  wound.  Now  lift  on  the  forceps,  and  in  this 
way  create  a  sort  of  funnel  with  smooth  sides,  over  which  the  bowel 
readily  glides  in  reduction. 

Do  not  attempt  to  reduce  by  rough  pressure,  which  may  contuse 
the  bowel.  If  "taxis"  fails,  there  is  a  method  which  will  surely 
succeed. 

Spread  a  large  compress  over  the  mass;  tuck  its  edges  well  under 
the  entire  circumference  of  the  wound;  and,  with  both  hands,  make  a 
gradual  pressure  on  the  mass  enveloped  in  the  compress,  coaxing  the 
refractory  loops  into  place  with  the  fingers,  and  at  the  same  time 
pushing  the  compress  further  under  the  abdominal  walls.  The 
assistant,  in  the  meantime,  lifts  up  on  the  forceps  attached  to  the  per- 
itoneum, raising  the  abdominal  walls  as  the  hernia  recedes. 

When  the  reduction  is  complete,  leave  the  compress  in  place,  se- 
cured by  forceps  until  repair  of  the  peritoneum  is  nearly  complete. 
Repair  the  abdominal  wall;  begin  by  suture  of  the  peritoneum  with 
small  catgut.  If  the  tension  is  great,  it  may  be  necessary  to  include 
the  muscular  plane  in  the  suture.  Next  repair  the  muscular  layers 
separately  by  continuous  chromic  gut  suture;  in  the  same  manner, 
the  aponeurosis,  and  finally  the  skin,  with  interrupted  silkworm-gut 
sutures. 

A  young  man  was  brought  to  the  City  Hospital  following  a  passage 
at  arms  with  his  prospective  father-in-law  who  had  given  him  the 
coup  de  grace  with  a  pocket  knife.  A  large  part  of  his  bowel  he  was 
carrying  wrapped  in  his  shirt  and  some  towels.  He  was  anesthetized 
and  the  examination  revealed  that  the  eventrated  gut  was  strangu- 
lated, having  crowded  through  a  very  small  peritoneal  wound  in  the 
lower  part  of  the  abdomen;  but  the  external  wound  was  extensive 
and  the  left  rectus  muscle  was  completely  divided. 

The  strangulated  loops  were  patiently  sponged,  one  by  one,  with 
normal  salt  solution  and  the  adjacent  skin  as  well.  Next  the  wound 
was  enlarged,  the  strangulation  relieved,  the  bowel  reduced  and  the 
peritoneum  repaired.  The  wound  and  adjacent  skin  were  next 
sponged  with  alcohol. 

The  ends  of  the  severed  rectus  were  widely  separated  and  were 
with  difficulty  brought  together  by  mattress  sutures. 

The  skin  and  fascia  were  repaired  without  drainage.     The  patient 


132  INJURIES    TO   THE   TRUNK 

recovered  with  no  rise  of  temperature  and  without  the  least  sign  of 
infection. 

Drainage  is  a  question  which  always  arises,  but  Lejars  assures  us 
that,  if  the  cleansing  is  carefully  carried  out,  drainage  is  in  no  wise 
necessary.  //  the  case  is  seen  late,  but  there  exist  only  a  few  soft  ad- 
hesions between  the  bowel  and  the  walls  of  the  wound,  the  same  dis- 
infection is  carried  out,  the  adhesions  around  the  orifice  gently 
broken  up,  and  the  mass  reduced,  as  before.  Drainage  is  quite 
indispensable,  if  there  are  already  the  signs  of  a  beginning  peritonitis. 

If  the  mass  has  become  the  site  of  a  purulent  peritonitis,  the  coils 
agglutinated  by  false  membrane,  and  gangrenous,  there  is  nothing 
to  do  except  to  keep  applied  moist  antiseptic  compresses,  which 
must  be  frequently  renewed.  If  the  patient  survives,  whatever 
intervention  is  needed,  may  be  undertaken  later. 


CHAPTER  XII 
GUNSHOT  AND  OTHER  WOUNDS  IN  MILITARY  PRACTICE 

The  care  of  the  wounded  in  battle  has  presented  in  all  ages  a 
constantly  varying  problem.  Historically  speaking,  time  and  place 
and  the  instruments  of  war  are  the  elements  of  the  retrospect. 
The  character  of  a  particular  age  is  dimly  reflected  in  the  character 
of  its  war  wounds,  and  these  regarded  as  finished  products  reveal, 
as  all  things  else  in  Nature,  an  evolutionary  aspect — a  gradual 
change  from  the  rudimentary  to  the  complex. 

The  cave  man,  our  earliest  progenitor,  sallied  forth  to  combat 
armed  with  a  shank  bone  or  an  unhewn  club  of  oak,  his  valorous 
purpose  to  inflict  upon  his  enemy  some  degree  of  contusion,  the 
simplest  form  of  wounds. 

The  very  best  his  efforts  might  hope  for  were  broken  bones,  or 
an  occasional  broken  head,  and  these  were  the  worst  the  primeval 
surgeon  had  to  manage.  At  a  later  stage  of  civilization  the  warrior 
had  learned  how  to  inflict  incised,  stab,  and  punctured  wounds. 
Finally,  it  has  remained  for  our  own  times  to  produce  the  worst 
wounds  of  all,  terrible  crushes  and  lacerations,  the  product  of 
machinery. 

The  European  War  has  proven  how  far  the  powers  of  destruction 
are  ahead  of  those  that  would  succor  and  save.  Former  wars  had 
taught  us  what  the  bullet  in  the  field  and  the  bacillus  in  camp  might 
do,  and  the  sanitary  service  prepared  itself  to  cope  with  these 
problems,  and  prepared  itself  efficiently.  But  the  unexampled  loss 
of  life  and  limb  along  the  Marne,  the  Yser  and  the  Vistula,  and  on  a 
hundred  other  battlefields,  left  the  Medical  Department  almost 
helpless  with  yet  new  problems  to  solve — problems  for  the  most  part 
unsolvable. 

The  artillery  aided  by  the  aeroplane  have  made  it  almost  im- 
possible to  give  the  wounded  adequate  First  Aid  and  the  first  aid 

^33 


134        GUNSHOT   AND    OTHER   WOUNDS   IN   MILITARY   PRACTICE 


Martini-Henry 


Guedes  Lee-Metford  Mauser         Krag-Jorgensen 


Fig.  86. — The  distinguishing  feature  of  the  rifle  is  the  spiral  grooving  which  gives  the 
projectile  a  rotary  movement,  maintained  throughout  its  flight  and  which  lessens  its 
tendency  to  depart  from  the  straight  line.  The  various  rifles  differ  with  respect  to  the 
number  of  grooves,  their  depth  and  the  angle  they  make  with  the  bore.  The  Martini- 
Henry  represents  the  first  form  of  the  modern  Breech  loading  gun — 0.45  caliber  conicai  leaden 
bullet  weighing  450  grains.     The  barrel  rifled  with  7  grooves,  with  one  turn  in  22  inches. 

The  later  rifles  have  smaller  bores,  fewer  grooves;  the  trajectory  is  less,  the  initiaWelocity 
and  the  range  much  greater;  the  steel  jacketing  diminishing  deformation. 

Lee-Metford  bullet,  caliber  0.303,  one  turn  to  10  inches  of  rifling. 

The  Krag-Jorgensen,  caliber  0.315,  initial  velocity  2034  feet  per  second  and  sighted  for 
2078  yards. 

The  Mauser,  caliber  0.311,  weight  of  bullet  154  grains,  velocity  2882,   range   2187   yards. 

The  U.  S.  Springfield,  caliber  0.300,  weight  150  grains,  velocity  2600  and  range  2850  yards. 


THE   ARMY  BULLET 


135 


dressing,  which  the  wounded  or  his  comrade  may  apply,  has  proven 
inadequate  for  the  tremendous  lacerations  of  bursting  bombs. 

Every  factor,  it  would  seem,  conspired  to  make  wound  infection 
the  great  surgical  feature  of  this  war.  The  character  of  the  wounds, 
the  lack  of  First  Aid,  the  delay  in  evacuating  the  wounded  and  the 
slowness  of  transportation  combined  to  give  the  pus,  the  tetanus, 
and  the  gas  bacillus  a  temporary  triumph  over  the  earnest  devotion 
of  the  highest  surgical  skill.  To  meet  these  conditions  the  efforts 
of  the  sanitary  service  in  the  future  must  be  directed. 

Under  what  may  be  called  the  normal  circumstances  of  war  the 
army  bullet  wound  still  maintains  the  characteristics  we  have  ascribed 
to  it  for  the  last  twenty  years.  These  wounds  vary  in  severity  from 
mere  contusions  through  all  the  grades  of  injury  to  destructive  lacera- 
tions, depending  upon  the  range.     If  the  gunshot  wounds  in  military 


Fig.  87. — Gold  coins  struck  by  a  bullet  fired  point  blank  at  a  Belgian  who  carried  the 
coins  in  his  belt.  He  was  stunned  by  the  impact  and  left  for  dead.  The  condition  of  the 
coins  indicates  the  force  of  the  bullet  and  its  tendency  to  deflect.  {Peacock,  Brit.  Jour. 
Surg.,  Jan.,  IQIS-) 

practice  differ  from  those  seen  in  civil  practice  with  respect  to 
character,  prognosis  and  treatment  it  is  because  the  bullets  in 
each  case  differ  with  respect  to  hardness,  range  and  initial  velocity 
and  because  the  wounds  are  produced  in  different  environments. 

The  modern  army  bullet  (Fig.  86)  is  of  small  caliber,  is  jacketed 
with  steel,  has  a  very  high  initial  velocity  and,  as  compared  with  the 
older  missile,  a  remarkable  range. 

The  small,  sharp-pointed  bullet,  used  by  most  of  the  combatants 
in  the    European  War,  produces  some  effects  differing  from  those 


136        GUNSHOT    AND    OTHER   WOUNDS   IN   MILITARY   PRACTICE 

produced  by  the  bullets  with  conical  tip.  These  results  are  based 
on  its  instability  of  flight.  Its  perforating  power  is  immense,  yet 
unless  it  strikes  squarely  on  the  point  it  is  most  easily  deflected 
(Fig.  87).  At  the  moment  of  oblique  impact  it  acquires  a  new  move- 
ment, viz.,  a  revolution  on  an  axis  transverse  to  the  line  of  flight.     In 


Fig.  88. — Showing  wound  of  entrance  at 
close  range  with  explosive  effect.  (Tuffier, 
Brit.  Jour.  Surg.,  Jan.,  1915-) 


Fig.   89. — Same,  showing  wound  of  exit. 

Note  tremendous  laceration.      (Tuffier,  Brit. 
Jour.   Surg.,  Jan.,  1915-) 


Other  words,  the  bullet  moves  forward  like  a  wheel.  According  to 
Makins,  if  the  velocity  at  moment  of  impact  is  not  great  it  may  make 
several  turns  in  the  tissues.  If  the  velocity  is  still  considerable  it 
may  turn  end  for  end  merely,  or  it  may  remain  vertical  to  its  path, 
making  only  a  half  turn.  In  all  these  cases  it  retains  to  the  last  the 
spin  on  its  long  axis,  imparted  by  the  rifling  of  the  gun. 


BULLET    WOUNDS    OF    SKIN 


137 


At  very  close  rani^c  all  these  l)ullets  are  tremendously  destructive 
to  all  the  tissues  alike. 

At  long  range  the  conical  bullet  tends  merely  to  perforate,  whereas 
the  pointed  bullet,  for  the  reason  given  above,  tends  to  tear  through 
the  tissues  in  any  other  position  than  point  first,  unless  striking 


Fig.  90. — Showing  small  entrance  wound  at  long  range;  large  irregular  wound  of  exit. 

(Makins.) 

squarely.  In  this  manner,  even  at  long  range,  explosive  effects  may 
be  produced.  However,  at  medium  or  long  range  the  various  tissues 
present  certain  general  characteristics. 

The  skin  presents  a  wound  of  entrance  smaller  than  the  bullet 
and  likely  to  be  dirty  and  discolored.  The  wound  of  exit,  if  present, 
is  larger,  more  irregular  and  bleeds  more  freely  (Figs.  88,  89  and 


138        GUNSHOT   AND   OTHER   WOUNDS   IN   MILITARY   PRACTICE 

90).     The  pain  in  flesh  wounds  is  often  moderate,  usually  a  burning 
sensation,  and  the  shock  is  not  severe. 

The  fascia  presents  a  smaller  opening  than  the  skin  and  is  likely 
to  be  slit  rather  than  cut  in  twain  and  so  tends  to  close  the  wound, 
oftentimes  materially  interfering  with  drainage. 

The  muscles  are  contused  and  lacerated,  often  infiltrated  with 

blood — conditions  favorable  to  infection. 
The  tendons  are  often  pushed  aside  and 
thus  escape  serious  injury.  At  other  times 
they  are  partly  or  v/holly  divided — condi- 
tions to  be  considered  in  the  course  of 
surgical  repair. 

The  blood  vessels  may  be  pushed  aside 
but  ordinarily  do  not  escape  if  in  the 
bullet's  track,  so  that  one  of  the  frequent 
causes  of  immediate  death  is  hemorrhage. 
Yet  even  in  the  case  of  laceration  of  the 
larger  arteries,  spontaneous  arrest  of  bleed- 
ing may  occur. 

Contusion  of  the  blood  vessel  results  in 
aneurism,  the  first  indication  of  which  is 
the  murmur  (Fig.  91).  The  subsequent 
character  depends  on  whether  or  not  in- 
fection occurs.      Heyrovsky  has  specially 

Fig.  91.— Traumatic  aneurism,       studicd    thcSC    iujuricS    and    pointS   OUt   the 
gunshot  wound.      (Moullin.)         j  i  •    i  j  i  i 

dangers,  which  are  secondary  hemorrhage, 
gangrene,  and  the  late  hemorrhage  following  prolonged  suppuration. 
Primary  gangrene  is  most  often  seen  in  w^ounds  of  the  popliteal, 
and  the  gangrene  sequent  to  these  injuries  is  of  the  moist  variety. 

In  the  non-infected  case,  secondary  hemorrhage  may  occur  as 
late  as  the  third  week.  The  vessel  in  such  cases  is  to  be  ligated  at 
the  site  of  injury  and  not  at  the  point  of  election.  The  injured 
vessel  is  exposed  and  followed  up  to  healthy  tissue  and  no  higher 
and  then  ligated,  the  wound  to  be  left  open  and  without  tamponade. 
Following  this  method  not  a  single  case  required  amputation.  Of 
twenty-one  infected  cases  three  died,  the  result  of  ascending  throm- 
bosis, and  five  more  were  cured  only  after  amputation. 


BULLET   WOUNDS   OF   NERVES 


139 


The  mortality  of  all  cases  of  secondary  hemorrhage  was  14.2  per 
cent,  as  compared  with  81.4  per  cent,  statistics  of  Billroth  in  1870. 
(Wiener  Klin.  Wochenschrift,  Feb.  11,  191 5.) 

The  uerjes,  like  the  tendons  and  blood  vessels,  may  be  pushed 
aside,  but  are  more  likely  to  be  contused  or  divided,  resulting  in 
paralysis — immediate  or  remote — neuralgia  or  trophic  disturbances, 
such  as  wasting  or  contractures  of  the  muscles,  or  degeneration  or 
inflammation  of  the  skin  corresponding  to  the  distribution  of  the 
injured  nerve.  Even  though  the  nerve  itself  is  not  directly  injured, 
these  conditions  may  later  result  from  its  inclusion  in  scar  tissue. 
It  is  often  necessary  to  expose  the  nerve  in  order  to  clear  it  of 
exudates  and  debris,  or  to  attempt  to  suture. 


Pig.  92. — Types  of  fracture  of  long  bones.  {Makins.)  (a)  Primary  lines  of  stellate 
fracture;  (b)  stellate  on  one  side,  transverse  on  the  other;  (c)  complete  wedge  broken  out;  (d) 
incomplete  wedge;  {e)  oblique  fracture. 


Gosset  calls  particular  attention  to  the  musculo-spiral  in  this 
connection  and  emphasizes  the  value  of  exposing  it  throughout  its 
whole  course  down  the  arm.  He  employs  for  this  purpose  an 
oblique  incision  extending  from  the  level  of  the  axillary  border 
behind  to  the  front  of  the  external  condyle,  the  arm  held  vertically 
and  the  elbow  flexed,  the  hand  near  the  face.  Division  of  the  fascia 
and  separation  of  the  muscles  readily  exposes  the  nerve,  which  lies 
in  close  contact  with  the  bone  throughout  its  course.  The  results 
have  been  such  as  to  encourage  this  procedure  in  every  case  of 
injury  with  symptoms  of  nerve  involvement.  (La  Presse  Medical, 
Jan.  21,  1915.) 


I40        GUNSHOT   AND    OTHER    AVOUNDS    IN    MILITARY   PRACTICE 

Bone  presents  a  wide  variation  in  the  character  of  the  lesions 
produced.  There  may  be  mere  puncture,  there  may  be  extensive 
comminution,  or  any  grade  of  injury  between  these  two  extremes 
(Figs.  92,  93). 

The  character  of  the  injury  will  depend  upon  two  factors:  (a) 
the  character  of  the  bone  and  (b)  the  range  of  the  bullet. 


Fig.  93- — Perforation  of  the  great  trochanter,  without  comminution.  Bullet  fired  at 
long  range  lodging  in  cancellous  tissue.  Note  position  of  bullet.  Bullet  was  not  removed. 
{Harris,  Brit.  Jour.  Surg.,  Jan.,  igis.) 

(a)  If  the  bone  is  soft  and  cancellous,  the  tendency  is  toward 
perforation;  if  it  is  hard  and  compact,  the  tendency  is  toward 
comminution. 

The  articular  end  of  the  long  bones,  the  short,  and  the  irregular 
bones  are  likely  to  be  merely  perforated.  On  the  other  hand,  the 
shaft  of  the  long  bones,  the  skull,  the  scapula  are  much  more  likely 
to  be  shattered. 

(b)  At  long  range,  perforation  is  rather  to  be  expected;  at  very 
close  range,  comminution  is  the  rule. 


GUNSHOT   FRACTURES 


141 


So  far  as  the  long  bones  are  concerned,  if  transverse  fracture 
occurs,  its  tendency  is  to  stop  short  of  the  articulation  (Fig.  95). 
With  respect  to  the  bones  of  the  limbs,  it  is  to  be  noted  that  the 


Fjg.  94.— Comminuted   fracture   of    the   femur.     Bullet  lodged   in   soft    parts.      {Harris, 

Brit.  Jour.  Surg.,  Jan.,  IQIS) 

exit  wound  will  be  the  more  comminuted  (Fig.  96).  Perforating 
fractures  without  solution  of  continuity  are  often  difficult  of  diag- 
nosis, because  of   the  absence  of  characteristic  symptoms.     The 


142        GUNSHOT    AND    OTHER   WOUNDS   IN   MILITARY   PRACTICE 


Fig.  95. — Lower  end  of  femur,  showing  tendency  of  fissures  to  stop  short  of  articular  ends. 

(Makins.) 


Fig.  96. — Small  wound  of  entrance  and  large  wound  of  exit  on  left  leg.     Fragments  of 
bone  carried  across  to  right  leg  producing  large  laceration,  requiring  amputation.      {Makins.) 


GUNSHOT  FRACTURES 


143 


Fig.  97. — Oblique  perforation,  implicating  both  epiphysis  and  diaphysis, 
with  large  fragment  at  exit.      (Makins.) 


Fig,  98. — Transverse  section  of  "gutter"  fracture.     (A)   No  loss  of  substance; 
(B)  comminution.     {Makins.) 


144 


GUNSHOT   AND    OTHER    WOUNDS   IN   MILITARY   PRACTICE 


diagnosis  is  to  be  made  by  reference  to  the  track  of  the  bullet, 
by  palpation,  and  from  presence  of  bone  dust  in  the  wound  of  exit, 
etc.  (Fig.  97). 

Comminuted  fractures  present  an  excessive  mobility,  and  often 
crepitus  is  hard  to  elicit.  Owing  to  "local  shock,"  the  limb  may 
be  quite  powerless  and  yet  painless. 


Fig.  99. — Gutter  fracture  perforating  skull  in  the  center  of  its  course.      (Makins.) 


Primary  shortening  is  often  absent  by  reason  of  the  muscular 
relaxation  due  to  shock.  Even  though  healing  takes  place  un- 
eventfully, a  large  amount  of  callus  is  likely  to  be  thrown  out  and, 
for  a  long  time,  the  union  will  not  be  strong. 

Acute  osteomyelitis  may  follow  infection.  On  the  other  hand, 
necrosis  may  occur  late  and  after  the  wound  has  apparently  quite 
closed. 

In  the  bones  of  the  skull  is  frequently  seen  the  so-called  "gutter 
fracture,"  in  which  there  are  usually  two  apertures  in  the  scalp. 


BULLET   WOUNDS    OF   THE   CRANIUM  145 

connected  by  a  trench  ploughed  through  the  outer  table  and  diploe 
(Figs.  98  and  99). 

The  corresponding  part  of  the  inner  table  is  comminuted  ex- 
tensively and  perhaps  depressed. 

The  length  of  the  gutter  depends  upon  the  surface  curvature,  and 
the  antero-posterior  are  more  serious,  as  a  rule,  than  the  transverse 
(Fig.  100). 

The  joints  present  effects  peculiarly  variant:  the  capsule  alone 
may  be  injured;  the  articular  ends  of  the  bones  may  be  guttered  or 


Fig.    100. — Superficial  perforating  fracture;  roof  lifted  at  both  openings.     i^Makins.) 

penetrated  with  or  without  injury  to  the  capsule;  there  may  be 
much  shattering,  fissures  radiating  in  all  directions;  or  the  joint  may 
be  involved  by  extension  from  the  wound  of  the  shaft.  The  bullet 
may  be  retained  in  the  joint  cavity.  Effusion  into  the  joint  is  a 
constant  symptom  following  perforation — a  mixture  of  blood  and 
synovial  fluid. 

Of  the  great  cavities  and  viscera,  each  has  its  own  particular 
symptomatology. 

The  cranium,  according  to  Von  Bergman,  presents  the  following 
lesions:  At  short  range,  the  skull  and  scalp  are  torn  to  pieces;  at 
160  feet,  the  scalp  is  preserved  but  the  skull  is  shattered;  there  are 
10 


146        GUNSHOT   AND    OTHER   WOUNDS   IN   MILITARY   PRACTICE 

two  openings  with  lacerated  edges  with  brain  exudate,  the  wound 
exit  always  larger  than  that  of  entrance. 

At  320  feet,  there  are  two  openings,  each  surrounded  by  a  series 
of  concentric  fissures  in  addition  to  radiating  fissures  (Fig.  loi). 

At  4000  feet,  the  radiating  fissures  still  appear. 

At  5600  feet,  entrance  and  exit  wounds  are  clean-cut  holes. 


Fig.   ioi. — Extensively  comminuted  gunshot  fracture,  bullet  fired  at  close  range.      (Senn 

after  Von  Bergman.) 


At  8000  feet,  there  is  only  the  wound  of  entrance,  and  the  bullet 
lodges  in  the  brain.  The  injuries  to  the  dura  mater  are  analogous  to 
those  of  the  skull. 

The  brain  itself,  semifluid,  is  torn  to  pieces  at  short  range,  through 
hydrodynam.ic  action.  At  long  range,  the  bullet  merely  traverses 
the  brain,  producing  areas  of  contusion  in  the  neighborhood  of  its 
track.  There  may  be  a  diffuse  hemorrhage  throughout  the  brain, 
the  ventricles  being  filled  with  blood. 


BULLET   WOUNDS    OF   THE   CRANIUM  147 

The  symptoms  arc  such  as  belong  to  concussion,  compression, 
contusion,  or  laceration  in  general. 

Thus  following  these  various  degrees  of  brain  injury  there  occur 
more  or  less  marked  indications  of  the  loss  of  brain  function,  both 
general  and  focal. 

Most  prominent  are  motor  and  sensory  paralysis;  impairment 
of  the  special  senses,  especially  sight  and  hearing;  aphasias  and 
amnesia — all  these  in  various  combinations. 

These  symptoms  usually  emanate  from  the  regions  adjacent  to 
the  track  of  the  bullet,  though  occasionally  it  is  evident  that  outlying 
portions  of  the  brain  have  suffered  as  well. 

The  amount  of  damage  which  the  brain  may  suffer  with  practical 
recovery  is  often  astounding.  Sometimes  it  would  seem  that  it  is 
merely  a  matter  of  controlling  pressure  and  infection. 

As  illustrating  this  point  we  may  instance  some  of  the  case  reports 
of  Whitehorne-Cole  in  service  at  one  of  the  British  evacuation 
hospitals  in  France. 

Case  I. — Compound  comminuted  fracture  of  skull  from  a  shrap- 
nell  bullet.  Longitudinal  sinus  along  vertex  of  the  skull,  and  the 
brain  substance  much  lacerated.  Trephining,  debridement,  disin- 
fection. Eighth  day  afterward,  mental  condition  good.  Partial 
motor  paralysis.  At  end  of  month,  paralysis  greatly  improved,  sent 
home  practically  well. 

Case  2. — Compound  comminuted  fracture  of  skull  from  rifle 
bullet  through  both  parietals.  Septic.  Aphasia,  right  hemiplegia. 
Disinfection.     Drainage. 

First  day  after  operation:  Aphasia,  hemiplegia,  urinary  incon- 
tinence. 

Fourth  day:  General  condition  much  improved.  Hernia  of  the 
brain  with  some  oozing  of  its  substance.     Alcohol  pack  applied. 

Sixteenth  day:     Hernia  practically  gone. 

One  month:  Wound  healed;  aphasia  gone;  hemiplegia  much 
improved;  can  read  and  talk  and  walk;  sent  home. 

Case  3. — Compound  comminuted  fracture  of  skull;  rifle  bullet 
through  left  frontal  and  temporal  region.  Left  facial  paralysis. 
Whole  track  of  bullet  laid  open.     Removal  of  fragments. 

Three  weeks  after:     Wound  healed  and  paralysis  gone. 


148        GUNSHOT   AND    OTHER   WOUNDS    IN   MILITARY   PRACTICE 

Case  4. — Compound  comminuted  fracture  of  right  parietal. 
Hernia  of  brain;  left  hemiplegia. 

Three  weeks  later:     Well  except  for  slight  paralysis  in  left  arm. 

Case  5. — Compound  comminuted  through  orbital  region.  Left 
eyeball  collapsed.     Hernia  cerebri.     Both  wounds  septic. 


Fig.    102. — Shrapnel  _bullet  lodged  in  body  of  the  vertebra.     Symptoms  of  concussion; 
complete  recovery.      (^Harris,  Brit.  Jour.  Surg.,  Jan.,  ipiS-) 

Did  remarkably  well  after  operation  until  fifth  day,  when  pulse 
and  temperature  began  to  rise.  Shortly  afterward  followed  by 
death. 

There  was  an  enormous  amount  of  bone  and  brain  destruction, 
and  that  he  should  have  done  so  well  for  five  days  is  very  remark- 
able.    (Lancet,  March  13,  1915.) 

The  spine  is  seriously  injured  in  proportion  as  the  cord  suffers 


BULLET    WOUNDS   OF    THE   THOR^W  1 49 

(Fig.  102).  Aside  from  the  cases  in  which  the  cord  lies  in  llie  track 
of  the  bullet  and  is  partially  or  completely  divided  transversely, 
there  are  those  cases  in  which  there  is  no  anatomical  lesion  of  the 
cord,  perhaps  nothing  more  than  perforation  of  a  vertebra,  yet  the 
functions  of  the  cord  are  markedly  depressed.  Absence  of  deej) 
reflexes  must  not  be  taken  to  indicate  complete  rupture  of  the  cord. 
This  may  be  due  to  "concussion"  of  the  cord,  which  Makins  de- 
scribes in  detail. 

The  degree  of  concussion,  and  therefore  the  degree  of  functional 
depression,  depends  directly  upon  the  velocity  of  the  ball. 

In  slight  spinal  concussion,  the  symptoms  consist  in  loss  of 
cutaneous  sensibility,  motor  paralysis,  and  vesical  and  rectal  in- 
competence, persisting  for  a  few  hours  or  even  two  or  three  days. 

Recovery  begins  with  return  of  sensation,  often  modified,  followed 
later  by  return  of  motor  activity. 

"Severe  concussion,  contusion  or  medullary  laceration,  may  be 
considered  as  lesions  of  equal  degree  as  to  severity,  bad  prognosis, 
and  unsuitability  for  active  interference;  all  characterized  by  the 
same  essential  phenomena,  viz.:  symmetrical  abolition  of  sensation 
and  motility,  absence  of  any  sign  of  irritation  in  the  paralyzed  area, 
and  loss  of  patellar  reflex.  These  severe  injuries  are  all  accompanied 
by  profound  shock.  The  patient  lies  still,  with  eyes  closed,  great 
pallor  of  surface,  the  sensorium  benumbed,  the  pulse  small  and 
irregular,  respiration  shallow"  (Makins). 

In  addition  to  these  lesions  there  are  such  as  arise  from  com- 
pression, either  from  bone  or  from  a  lodged  bullet.  But,  as  Makins 
says,  it  may  be  assumed  that  a  bullet  injuring  the  vertebra  suffi- 
ciently to  displace  bone,  has,  at  the  same  time,  produced  grave 
lesions  of  the  cord.  If  the  pressure  is  due  to  the  bullet,  it  argues 
that  its  velocity  was  low  and  that  there  may  be  no  serious  lesion  of 
the  cord  and  that  the  symptoms  are  those  of  compression  alone. 
Compression  due  to  extra-dural  hemorrhage  can  rarely  produce 
serious  symptoms. 

The  thorax  may  or  may  not  be  penetrated  by  the  impact  of  a 
bullet,  though  penetration,  of  course,  is  the  rule,"  and  these  wounds 
constitute  a  large  part  of  the  casualties  of  battle.  The  non-penetrat- 
ing "wounds  present  no  features  of  especial  interest.     The  skin  and 


150        GUNSHOT   AND    OTHER   WOUNDS   IN    >nLITARY   PRACTICE 

muscles  may  be  injured  in  various  degrees  between  simple  perfora- 
tion and  serious  laceration.  The  clavicle  and  scapula  may  be 
fractured;  the  axillary  space  may  be  involved,  with  serious  results. 

The  penetrating  wounds  cross  the  thorax  in  every  direction, 
transversely,  longitudinally,  and  obliquely. 

Those  which  traverse  the  thorax  longitudinally,  and  are  received 
while  firing  or  advancing  in  the  prone  position,  are  noteworthy  in 
that  the  abdominal  cavity  is  usually  also  involved.  The  abdominal 
cavity  is  also  likely  to  be  penetrated  when  the  base  of  the  thorax|is 
crossed. 

If  a  rib  is  involved,  the  bone  injury  is  usually  limited,  and  these 
fractures  are  considered  of  importance  only  when  the  intercostal 
artery  is  wounded.  In  many  of  these  fractures  from  the  army  bullet 
the  ordinary  symptoms  are  absent,  either  because  of  the  localized 
character  of  the  injury  and  absence  of  contusion  of  the  soft  parts,  or 
because  the  fragmentation  in  the  track  of  the  bullet  is  so  complete 
as  to  preclude  crepitus. 

The  lungs,  almost  certain  to  be  involved  in  perforating  wounds  of 
the  chest,  escape  with  remarkably  slight  damage,  owing  to  their 
elasticity. 

Those  bullets  which  pass  near  the  root  of  the  lungs  are  very  likely 
to  involve  the  great  vessels,  followed  by  rapid  and  fatal  internal 
hemorrhage. 

Certain  svTnptoms  manifest  themselves  in  most  cases  of  lung 
injurv  in  some  degree.  Shock,  if  it  exists  at  all,  is  not  usually 
serious  and  arises  rather  from  the  injury  to  the  chest  wall;  nor  are 
pain  and  dyspnea  prominent. 

Hemoptysis  is  fairly  constant,  but  not  persistent  longer  than  two 
or  three  days.  Cough  is  seldom  troublesome  and  pneumothorax  is 
rare. 

Hemothorax  is  very  frequent,  but  in  the  great  majority  of  cases  is 
due  to  hemorrhage  from  the  chest  walls — to  the  intercostals  rather 
than  to  the  lung  injury. 

Tuffier  remarks  of  these  cases  as  observed  in  the  French  field  and 
base  hospitals  that  bullet  wounds  of  the  chest — such  as  reach  the 
hospital — are  generally  remarkably  mild  and  cases  of  hemothorax 
requiring  intervention  are  quite  exceptional. 


BULLET   WOUNDS   OF   THE   THORAX 


151 


From  one  of  the  field  hospitals  comes  this  report  which  is  typical: 
"Cases  4,  5,  6— perforating  bullet  wound  of  the  chest.  These  cases 
were  of  comparatively  benign  character.  Each  showed  the  following 
signs  and  symptoms:  pain,  dyspnea,  slight  hemoptysis,  immobility 
of  one  side  of  the  chest  and  signs  of  free  fluid  in  the^base.  They  all 
did  well  during  their  stay  with  us. 

Case  7. — Perforating  chest  wound  of  more  serious  character.  In 
this  case  the  right  hemothorax  showed  rapid  increase  of  the  fluid 
with  displacement  of  the  heart  and  urgent  dyspnea.  We  tapped  the 
chest  drawing  off  3  pints  of  blood-stained  fluid.  Two  days  later 
there  were  signs  of  air  in  the  pleura,  but  after  a  second  tapping, 
which  drew  off  air  and  pus,  the  patient  made  a  sufficient  recovery  to 
be  moved"  (British  Journal  of  Surgery,  Jan.,  19 15). 

The  symptoms  of  a  hemothorax  reach  their  full  height  on  the  third 
or  fourth  day.  The  pain  is  severe,  the  pulse  and  temperature  rise, 
dyspnea  is  prominent,  respiratory  movement  on  the  affected  side  is 
annulled,  and  there  are  the  physical  signs  of  fluid  on  the  pleura. 

The  course  of  the  temperature  is  a  matter  of  concern,  for  the  fever 
suggests  empyema.  It  seems  always  to  rise  pari  passu  with  the 
increase  of  blood  in  the  pleural  cavity,  often  declining  after  the 
third  or  fourth  day,  always  falling  after  a  paracentesis  and  rising 
anew  with  fresh  access  of  pleural  hemorrhage.  On  the  other  hand, 
the  fever  of  infection  arises  later,  persists,  or  gradually  mounts 
higher. 

Perforating  wounds  of  the  heart  in  warfare  Makin  regards  as 
certainly  fatal,  believing  that  the  cause  of  death  is  not  hemorrhage, 
but  sudden  stoppage  of  the  heart  action. 

Senn  believes  that  death  usually  occurs  from  compression  of  the 
heart,  due  to  hemorrhage  within  the  pericardium.  In  those  cases 
where,  from  the  anatomical  features,  the  heart  would  seem  to 
be  involved  and  yet  presents  no  symptoms  of  injury,  the  inference 
must  be  that  it  escaped,  owing  to  change  in  position  and  size 
incident  to  contraction. 

Other  observers  write  that  a  bullet  has  been  known  to  pass  through 
the  heart  without  fatal  effect. 

Penetrating  wounds  of  the  abdomen  are  seldom  simple  in  character, 
for  it  only  rarely  happens  that  a  single  viscus  is  involved.     The  one 


152         GUNSHOT   AND    OTHER    WOUNDS   IN   MILITARY   PRACTICE 

symptom  which,  if  it  occurs  at  all,  is  common  to  wounds  of  all 
abdominal  organs,  is  peritonitis.  The  sources  of  hemorrhage  are 
numerous.  The  degree  of  injury  to  every  organ  decreases  with 
increased  range.     The  small  intestine  is  naturally  the  structure  most 


Fig.  103. — Perforating  wounds  of  small  intestine,  (a)  Entry;  (b)  exit.  Note  slit-like 
character  and  aversion  of  mucous  membrane;  localized  ecchymosis  more  abundant  around 
exit  aperture.     {Makins,  from  St.  Thomas  Hospital  Museum.) 


frequently  wounded  and,  of  course,  its  perforations  are  multiple 
(Fig.  103). 

•  Pain,  collapse,  vomiting,  and  peritonitis  are  nearly  always  present, 
although  present  also  in  wounds  of  the  stomach  and  large  intestine. 
The  peritonitis  is  more  widespread  in  the  case  of  the  small  intestine 


TREATMENT    OF   BULLET   WQUNDS  1 53 

than  in  the  case  of  the  stomach  and  large  intestine,  because  of  the 
greater  activity  and  motihty  of  the  small  intestine.  Vomiting  of 
blood  may  be  taken  to  indicate  perforation  of  the  stomach.  The 
stomach  and  intestines  escape  "explosive"  effects  in  proportion  as 
they  are  empty  at  the  time  of  injury. 

The  bladder  when  wounded  may  present  two  openings;  both  may 
be  extra-peritoneal,  both  may  be  intra-peritoneal,  or  one  may  be 
intra-  and  the  other  extra-peritoneal.  An  extra-peritoneal  wound 
bleeds  the  more  profusely;  an  intra-peritoneal  wound  permits  the 
escape  of  urine  into  the  peritoneal  cavity.  Hematuria,  or  suppressed 
urination  with  an  empty  bladder,  points  to  the  character  of  the 
injury. 

The  liver  is  likely  to  be  simply  perforated  or  notched,  though  at 
close  range  "explosive"  effects  are  observed.  The  chief  result  is 
hemorrhage  and,  in  some  cases,  an  escape  of  bile,  due  to  injury  to  the 
gall-bladder  or  the  bile  ducts. 

The  spleen  if  merely  perforated  gives  rise  to  hemorrhage,  usually 
insignificant,  unless  its  main  vessels  are  involved. 

The  kidneys  give  rise  to  either  extra-  or  intra-peritoneal  hemor- 
rhage, which  is  not  serious  unless  the  perforation  involves  the 
hilum.  Shock  is  nearly  always  present  as  well  as  hematuria  and 
frequent  urination. 

The  pancreas:  there  is  no  way  by  which  injury  to  the  pancreas 
may  be  diagnosed.  It  may  be  merely  inferred  from  the  course  of 
the  bullet.  It  is  so  situated  that  it  cannot  be  reached  by  a  bullet 
without  injur}-  to  other  organs  more  likely  to  give  due  notice  of  their 
affront. 

PROGNOSIS  AND  TREATMENT 

Flesh  wounds  produced  by  the  army  bullet  and  uncomplicated 
by  infection  tend  to  heal  without  difficulty.  Whether  or  not  in- 
fection occurs  depends  upon  the  efficiency  of  the  first-aid  dressing — 
that  is  to  say  whether  it  is  ample  and  whether  it  is  applied  in  due 
time. 

The  aim  of  the  first  dressing  is  to  secure  aseptic  occlusion  but  if 
the  wound  is  exposed  to  infection  from  sources  other  than  the  bullet 


154        GUNSHOT   AND   OTHER   WOUNDS   IN   MILITARY   PRACTICE 

before  the  dressing  is  employed,  the  wound  may  as  well  be  regarded 
as  infected. 

Again  if  the  wound  is  large  and  lacerated,  even  if  the  dressing  is 
applied  at  once,  infection  is  almost  certain  to  occur.  Consequently 
some  form  of  antiseptic  treatment  is  to  be  carried  out  in  these  cases. 
This  will  ordinarily  be  done  at  the  field  hospital. 

Many  observers  in  the  European  War  condemn  the  use  of  iodine, 
asserting  that  it  does  not  agree  with  these  wounds,  tending  to 
produce  irritation,  inflammation,  or  even  sloughing  of  the  parts. 
If  these  effects  occur,  however,  it  is  probably  not  the  fault  of  the 
remedy  but  rather  the  fault  of  the  user.  If  the  iodine  solution  is 
poured  into  an  open  vessel,  the  alcohol  evaporates,  the  solution 
becomes  more  and  more  concentrated  and  of  such  strength  as 
finally  to  be  noxious  to  the  tissues.  Alcohol  and  iodine  will  probably 
remain  for  some  time  to  come  the  antiseptic  agents  most  available 
for  such  work. 

In  the  base  hospital  the  treatment  of  the  wound  which  has  become 
septic  presents  a  different  problem.  A  larger  choice  of  antiseptics 
is  here  permissible.  It  is  evident  from  the  many  reports  on  this 
subject  that  the  ideal  antisepsis  for  extensive  suppurations  has  not 
yet  been  found. 

Carbolic  acid,  bichloride  of  mercury,  peroxide  of  hydrogen, 
boracic  acid — each  of  a  long  list  of  germicides — has  its  special 
indications.  A  solution  of  i  to  100,000  nitrate  of  silver  has  been 
highly  recommended.  Oftentimes  it  is  indicated  to  enlarge  the 
wound  and  search  for  a  piece  of  the  clothing  or  other  foreign  body, 
though  it  is  unnecessary  to  say  that  no  such  search  should  be  carried 
out  unless  sepsis  supervenes.  Under  no  circumstances  is  the  bullet 
to  be  probed  for.  In  prolonged  suppurations  the  use  of  vaccines  will 
often  be  found  useful.  In  the  case  of  the  limbs,  these  bullet  wounds 
of  the  soft  parts,  even  as  in  the  case  of  shell  wounds,  may  call  for 
primary  amputation  when  the  blood  supply  is  compromised  beyond 
the  hope  that  a  collateral  circulation  may  be  established.  Skene 
recommends  in  the  case  of  large  suppurating  areas  that  antiseptic 
sawdust  be  used.  The  affected  area  is  covered  with  a  gauze  sheet, 
the  sawdust  poured  on  and  the  edges  of  the  gauze  folded  over  to 
hold  the  dressing,  the  whole  to  be  changed  every  two  or  three  hours. 


TREATMENT  OF  GUNSHOT  FRACTURES 


155 


Finally,  tetanus  or  the  gas  bacillus  infection  may  supervene,  each 
requiring  its  special  treatment.     (See  page  285.) 


TREATMENT  OF  GUNSHOT  FRACTURES  OF  THE  LONG 

BONES 

The  treatment  of  gunshot  fracture  of  the  long  bones  varies  in 
detail,  depending  upon  the  character  of  the  injury  to  the  bone  and 


Fig.   104. — Simple  perforating  frac-  Fig.     105. — Extensive   comminution    with 

ture  of  the  lower  end   of    the    tibia,      moderate  injury  to  the  soft  parts.     {Harris, 
(Makins.)  Brit.  Jour.  Surg.,  Jan.,  igiS-) 

to  the  soft  parts.  On  this  basis,  three  clinical  varieties  may  be 
recognized:  (a)  Simple  perforating  fracture  (Fig.  104);  (b)  ex- 
tensive comminution  with  moderate  injury  to  the  soft  parts  (Fig. 
105);  (c)  extensive  comminution  with  great  laceration  and  de- 
struction of  the  soft  parts  (Fig.  106). 


156        GUNSHOT    AND    OTHER    WOUNDS    IN   MILITARY   PRACTICE 

(a)  The  treatment  of  uncomplicated  perforating  fracture  is 
exceedingly  simple:  Aseptic  occlusion  and  immobilization  and, 
provided  only  that  infection  is  kept  out  of  the  wound,  the  results  are 
uniformly  excellent. 

(b)  In  this  case,  conservatism  is  still  the  better  course;  the  wound 
in  the  soft  parts  is  cleansed  and  dressed,  the  bones  adjusted  and  an 


Fig.    106. — Extensive   comminution   with   great    laceration   of    the   soft    parts,   requiring 
amputation.      {Harris,  Brit.  Jour.  Surg.,  Jan.,  1915.) 

emergency  splint  applied  until  such  time  as  the  more  definite  treat- 
ment can  be  instituted. 

(c)  In  case  the  bones  are  shattered,  the  soft  parts  reduced  to 
pulp,  it  is  better  to  proceed  to  immediate  amputation.  It  is  under 
these  circumstances  that  Fitz  Maurice  Kelley  recommends  the 
simple  circular  amputation  of  the  member,  dividing  all  the  tissues 
at  the  same  level,  making  no  effort  to  fashion  a  flap.  After  the 
dangers  of  infection  are  passed,  another  amputation  following  the 
usual  lines  is  to  be  practised. 


TREATMENT  OF  GUNSHOT  FRACTURES  T57 

The  question  of  immobilization  is  complex.  On  the  field  shaped 
splints  of  zinc  or  molded  wire  splints  may  be  employed.  Tuffier, 
however,  expresses  preference  for  the  wooden  splint  fashioned  and 
padded  in  the  ordinary  way.  He  praises  its  simplicity  and  efficiency. 
At  the  field  and  base  hospitals  no  such  simple  routine  can  be  followed 
and  each  case  must  be  treated  according  to  its  character,  taking  into 
account  the  degree  of  fragmentation,  the  tendency  to  displacement, 
the  requirements  of  frequent  change  of  dressing  of  the  soft  parts  and 
the  comfort  of  the  patient. 

In  the  ordinary  fracture,  with  absence  of  wound  infection,  the 
plaster  splint  remains  the  dressing  of  choice. 

In  the  case  of  the  greatly  comminuted  fracture  with  serious  sup- 
purations to  be  treated,  the  problem  of  maintaining  coaptation 
while  handling  the  limb  in  doing  the  dressings  is  one  difficult  to  solve. 

E.  W.  Hey  Groves,  in  the  British  Journal  of  Surgery  (Jan.,  1915), 
has  pointed  out  the  value  of  continuous  extension  in  this  class  of  cases 
and  the  manner  in  which  the  principle  may  be  applied  to  the  indivi- 
dual fractures.  Two  methods  he  holds  in  reserve:  first,  extension 
splints,  modifications  of  those  invented  by  Borchgevrink;  second, 
transfixion  apparatus. 

The  splint  for  the  humerus  is  a  Y-shaped  wooden  piece,  the  crutch 
padded  for  the  axilla  and  the  end  extending  beyond  the  elbow  and 
fitted  with  a  pulley  wheel.  A  stirrup  of  adhesive  plaster  is  fixed  to 
the  lower  part  of  the  arm  and  a  perforated  wooden  bar  fitted  into  the 
stirrup.  The  splint  is  now  adjusted  to  the  axilla  and  inner  aspect 
of  the  arm  and  fixed  with  adhesive  strips.  A  cord,  attached  to  the 
wooden  stirrup,  is  passed  through  the  pulley  and  brought  around  to 
the  inner  surface  of  the  splint  where  it  is  fastened  with  whatever 
tension  may  be  desired. 

Groves  fastens  the  pulley  cord  to  a  solid  rubber  band  arranged  as 
a  loop  on  the  inner  side  of  the  splint,  to  perfect  the  continuous 
extension. 

When  the  danger  of  infection  does  not  contra-indicate,  he  applies 
the  double  transfixion  apparatus  pictured  in  connection  with  the 
femur  (Fig.  113). 

The  upper  end  of  the  humerus  is  transfixed  at  a  point  in  the  line 
between  the  inner  and  outer  border  of  the  arm,  and  at  the  level  just 


158        GUNSHOT   AND    OTHER   WOUNDS   IN   MILITARY   PRACTICE 

below  the  middle  of  the  deltoid,  avoiding  the  cephalic  vein  and  the 
circumflex  nerve. 

The  lower  pin  is  passed  through  the  humerus  from  side  to  side, 


Fig.  107. — Posterior  angular  splint  for  forearm  with  full  supination.  Note  manner 
in  which  the  extension  cord  passes  through  the  pulley  and  to  the  rubber  bands  on  back  of 
splint.      {Groves,  Brit.  Jour.  Surg.,  Jan.,  1915.) 

J^  inch  above  the  epicondyles.  Before  the  lower  pin  is  passed, 
a  perforated  iron  hoop  is  adjusted  over  the  elbow  and  the  pin 
passed  through  the  proper  perforations  to  hold  the  hoop  in  position. 


Fig.  108. — Antero-internal  splint  for  forearm,  when  the  elbow  and  ulna  are  involved 
Note  the  position  of  the  rubber  bands  on  internal  surface  to  which  the  extension  cord  is 
attached.     {Groves,  Brit.  Jour.  Surg.,  Jan.  19 15.) 

Extension  bars  are  now  fitted  to  the  transfixion  pin  above  and  to  the 
hoop  below.  The  screws  of  the  extension  bars  permit  of  powerful 
extension,  correction  of  lateral  angulation  and  rotation,  and  ready 


TREATMENT  OF  GUNSHOT  FRACTURES 


159 


Fig.   109. — Antero-internal  splint  applied  to  patient  in  the  2nd  Southern  General  Hospital, 
with  fracture  of  the  ulna.     {Groves,  Brit.  Jour.  Surg.,  Jan.,  igiS-) 


Fig.   lie. — Radiogram  of  elbow  shown  in  Fig.  no.     Note  that  the  head  of  the  radius  is  in 
good  position  as  a  result  of  the  extension.     {Groves,  Brit.  Jour.  Surg.,  Jan.,  IQIS-) 


l6o        GUNSHOT   AND    OTHER    WOUNDS    IX   ^HLITARY   PRACTICE 

access  of  wounds.     Of  course  the  sepsis  connected  with  the  trans- 
fixion pins  is  the  objection  to  this  method  to  be  overcome. 

In  the  case  of  the  forearm  a  posterior  angular  sphnt  is  recom- 
mended, applying  the  same  principle  of  extension  as  in  the  case  of 
the  humerus.  The  extension,  in  the  form  of  an  adhesive  plaster 
stirrup,  is  attached  to  the  forearm  and  by  means  of  cord  and  pulley 


Fig.    III. — Antero-internal  splint  applied  to  fractures  above  and  below  elbow.     The  splint 
with    extension   reduces    both   fractures.     (Groves,  Brit.  Jour.   Surg.,  Jan.,  1915.) 

the  traction  is  exerted  on  the  forearm,  the  arm  being  fixed  to  the 
upright  piece  of  the  sphnt.  The  cord  is  attached  to  an  elastic 
rubber  band  on  the  back  of  the  forearm  piece  (Fig.  107).  The 
forearm  is  thus  fixed  in  complete  supination. 

In  case  of  a  wound  on  the  back  of  the  member,  it  may  be  neces- 
sary to  employ  a  metal  frame  splint  with  two  lateral  bars  for  the 
forearm,  the  extension  being  applied  in  the  same  manner. 


TREATMENT  OF  GUNSHOT  FRACTURES 


l6l 


In  case  the  elbow  is  involved  with  comminution  of  the  ulna  and 
laceration  of  the  forearm,  an  antero-internal  splint  is  recommended 
(Fig.  io8),  leaving  the  whole  outer  and  posterior  surface  accessible 
for  dressings.  The  same  sort  of  pulley  extension  is  used.  This 
splinting  prevents  dislocation  of  the  head  of  the  radius. 


Fig.    112. — Comminuted  fracture  of  the  tibia  and  fibula.     Part  of  shell  in  situ.     Belgian 
soldier  in  2nd  Southern  General  Hospital.      (Brit.  Jour.  Surg.,  Jan.,  1915.) 


Fig.  109  indicates  the  manner  in  which  the  splint  is  attached. 
Fig.  1 10  is  a  radiogram  of  the  arm  pictured  above.  This  splint  is  appli- 
cable also  to  fractures  involving  the  lower  end  of  the  humerus  alone. 

In  the  case  pictured  in  Fig.  iii,  the  patient,  a  Scotchman,  in  a 
Paris  hospital,  had  a  fracture  of  the  lower  end  of  the  humerus  and 
the  ulna.     Both  fractures  were  reduced  and  held  by  this  splint. 


II 


l62        GUNSHOT   AND   OTHER    WOUNDS   IN    MILITARY   PRACTICE 

Fractures  of  the  tibia  and  fibula  present  points  of  special  impor- 
tance because  of  the  probability  that  the  blood  supply  will  be  com- 
promised and  all  the  soft  parts  implicated;  and  in  the  case  of  the 
ends  of  the  bones,  the  joints  will  be  involved  (Fig.  112). 


Fig.  113. — Double  transfixion  apparatus  applied  to  the  femur.  Note  the  absence  of 
parallelism  of  the  transfixion  pins,  the  manner  in  which  the  metal  hoop  is  attached  to  the 
lower  pin,  and  the  manner  in  which  the  screw  extension  bars  connect  upper  pin  with  hoop 
below.      {GroveSf  Brit.  Jour.  Surg.,  Jan.,  1915.) 

The  transfixion  apparatus  is  specially  recommended  for  these 
conditions.  One  pin  passes  transversely  through  the  head  of  the 
tibia,  the  other  through  the  malleoli  or  os  calcis.  The  same  mechan- 
ism as  described  for  the  humerus,  consisting  of  a  perforated  hoop 
with  lateral  extension  bars,  is  adjusted  to  these  transfixion  pins. 

These  compound  fractures  of  the  upper  end  of  the  femur  present 
greater  difficulties  of  management  than  almost  any  other  class  of 


TREATMENT  OF  GUNSHOT  FRACTURES 


163 


gunshot  injuries.  There  is  always  great  chance  of  infection,  not  to 
speak  of  the  pain  which  the  patient  suffers  in  transportation  and 
dressing. 


Fig.   114. — Fractured  femur  treated  by  the  double  transfixion  apparatus  with  little  resulting 
deformity.     (Groves,  Brit.  Jour.  Surg.,  Jan.,  ipiS-^ 

Immobilization,  in  many  cases,  it  seems  almost  impossible  to 
secure.  The  double  transfixion  apparatus  may  be  applied  to  these 
cases  with  prospect  of  excellent  results  (Fig.  113).  The  inner 
transfixing  pin  is  passed  through  the  base  of  the  great  trochanter 


164        GUNSHOT   AND    OTHER    WOUNDS    IN   MfLITARY   PRACTICE 


Pig.  115. — Wooden  trough  splint  for  leg  fracture.  Note  angles  of  inclination  of  thigh 
and  leg.  Sides  are  removable,  permitting  access  to  the  wounds.  {Groves,  Brit.  Jour. 
Surg.,  Jan.,  1915-) 


Fig.  116. — Cradle  splint.  Note  manner  in  which  weight  is  attached  to  the  foot-piece- 
By  lifting  the  foot-piece  to  which  the  foot  is  bandaged,  the  limb  may  be  handled  without 
disturbing  the  traction.     (Groves,  Brit.  Jour.  Surg.,  Jan.,  191S) 


TREATMENT  OF  GUNSHOT  FRACTURES 


165 


antcro-postcriorly.  The  lower  pin  passes  from  side  to  side  through 
the  condyles.  Even  in  the  most  severely  comminuted  shafts  good 
union  may  be  obtained  (Fig.  114). 

In  many  of  the  septic  cases  it  will  not  be  feasible  to  carry  out  this 
plan  and,  again,  other  forms  of  treatment  must  be  available  where 


Fig.  117. — The  Florschutz  method  of  suspension  and  extension  in  the  case  of  fractures 
of  the  upper  end  of  the  femur  is  more  easily  adjusted  than  the  Hodgen  spHnt.  The  uprights, 
which  support  the  horizontal  bar,  can  be  attached  to  any  bed  and  the  pulley  can  be  attached 
to  any  height.  In  this  case,  a  patient  from  the  2nd  Southern  General  Hospital,  a  12-pound 
bag  of  sand  is  used  for  extension.      (Groves,  Brit.  Jour.  Surg.,  Jan.,  1915.) 


there  is  lack  of  mechanical  skill  in  the  adjustment  of  such  an 
apparatus. 

The  wooden  trough  splint  is  simple  and  fairly  efficient  (Fig.  115). 
It  is  provided  with  two  inclines,  one  for  the  thigh  at  an  angle  of 
forty-five  degrees  and  one  for  the  leg.  The  foot  is  bandaged  to  the 
foot-piece  and  the  sides  are  removable  to  facilitate  the  dressings. 

The  cradle  splint  operates  on  the  same  principle,   except  that 


1 66        GUNSHOT   AND    OTHER    WOUNDS   IN    MILITARY   PRACTICE 

extension  is  added  to  position.  The  foot  is  bandaged  to  the  foot- 
piece  and  to  this  the  weight  is  attached  (Fig.  ii6).  It  permits 
the  limb  to  be  moved  without  relaxing  the  pull  of  the  extension 
weight,  by  lifting  the  foot-piece  off  the  frame. 

For  wounds  and  fractures  near  the  hip  joint  the  Florschiitz 
method  is  simple  and  efficient,  the  thigh  and  leg  being  slung  from  a 
bar  above  the  bed  (Fig.  117). 

TREATMENT  OF   GUNSHOT  WOUNDS   OF  JOINTS  ' 

In  the  simple  perforating  cases  the  skin  is  sterilized,  the  wound 
dressed  and  the  joint  immobilized.  As  soon  as  the  wound  is  healed, 
begin  with  cautious  passive  motion  and,  usually,  an  excellent 
functional  result  is  obtained.  If,  on  the  other  hand,  suppuration 
occurs,  arthrotomy  is  indicated.  If  there  is  much  comminution 
to  begin  with,  the  soft  parts  lacerated,  it  will  often  be  better  to 
amputate. 

The  shoulder-joint  usually  furnishes  a  good  prognosis  while,  on 
the  other  hand,  the  hip -joint  presents  a  bad  outlook  on  account  of 
infection  and  of  complications  involving  the  rectum,  bladder,  etc. 

The  knee-joint  is  very  frequently  wounded  and  the  damage 
is  always  serious.  Hemorrhage  into  the  joint  is  a  constant  feature, 
the  hemarthrosis  disappearing  in  about  a  month  in  the  favorable 
cases.  Under  conservative  and  expectant  treatment  the  results  are 
surprisingly  good. 

TREATMENT  OF  GUNSHOT  WOUNDS  OF  SKULL  AND 

BRAIN 

Most  perforating  wounds  of  the  skull  prove  fatal.  The  fatalities 
increase  as  the  range  of  the  bullet  shortens  and  as  the  impact  ap- 
proaches the  base  of  the  skull,  death  resulting  from  injury  to  the 
automatic  centers.  The  most  recoveries  follow  injury  to  the 
frontal  lobes.  Blindness  may  result  from  injury  to  the  occipital 
lobes.  Primary  union  of  the  scalp  wound  is  an  element  in  favorable 
prognosis,  since  by  this  means  infection  is  more  Hkely  to  be  ehminated. 

First  aid  on  the  battlefield  will  look  to  the  hemorrhage.  The  first- 
aid  dressing  should  include  both  the  wound  of  entrance  and  exit. 
In  the  case  of  external  hemorrhage,  packing  the  wound  is  contra- 


TREATMENT  OF  GUNSHOT  WOUNDS 


167 


indicated;  a  few  strips  of  sterile  gauze  loosely  packed  in  the  wound 
will  favor  hemostasis  and  antisepsis.  At  the  field  hospital  a  cra- 
niectomy should  be  done. 

All  surgeons  experienced  in  recent  wars  agree  on  the  necessity  of 
exploring  every  such  wound  as  soon  as  possible.  Where  long  trans- 
portation is  necessary  before  a  trephining  can  be  done,  the  mortal- 


FiG.   118. — Bullet  in  the  tentorium  cerebelli.     Large  clear  space  above  indicates  part  of  skull 
blown  away.     Operation;  good  recovery.     {Harris,     Brit.  Jour.  Surg.,  Jan.,  1915-) 

ity  is  naturally  greatly  increased.  Enlarging  the  wound  in  the 
scalp,  enlarging  the  wound  in  the  skull  sufficiently  to  remove  all  frag- 
ments of  bone  and  debris,  controlling  the  hemorrhage  and  providing 
drainage — these  represent  the  chief  elements  of  relief.  (See  Urgent 
Craniectomy.)  If  infection  occurs  the  wound  is  to  be  opened  up. 
Disturbances_of  the  sensorium,  of  motion  and  sensation  often  improve 


1 68        GUNSHOT    AND    OTHER    WOUNDS    IN    MILITARY   PRACTICE 


Fig.    119. — Bullet  lying  in  the  petrous  portion  of  the  temporal  bone.     Treated  by  temporal 
decompression;  bullet  left  in  situ;  good  recovery.      (Harris,  Brit.  Jour.  Surg.,  Jan,,  1915.) 


Fig.  120. — Bullet  lying  in  tentorium  cerebelli,  having  entered  left  parietal  region. 
Marked  cereVjral  compression.  Wound  of  entrance  trephined.  Bullet  removed  later,  tre- 
phining the  right  occipital  region.     Good  recovery.     {Harris^  Brit.  Jour.  Surg.,  Jan.,  1915.) 


TREATMENT  OF  GUNSHOT  WOUNDS  1O9 

as  by  magic  following  these  interventions.     Astudy  of  the  case  reports 
from  European  hospitals  confirms  these  views  (Figs.  ii8,  119,  120). 

TREAT.MENT  OF  GUNSHOT  WOUNDS  OF  THE  FACE 

The  chief  dangers  in  these  wounds  are  hemorrhage,  infection  and 
interference  with  respiration.     The  eye,  the  fifth  and  seventh  nerves, 


Fig.  121. — Bullet  lodged  in  the  base  of  the  neck,  .having  first  perforated  the  tuberosity 
of  the  humerus  and  the  acromion  process.  Note  that  the  bullet  is  turned  end  for  end  and  is 
pointing  at  the  wound  of  entrance.      (.Harris,  Brit.  Jour.  Surg.,  Jan.,  1915.) 

are  most  likely  to  be  involved  and  these  injuries  are  to  be  treated  on 
general  principles.  Control  of  hemorrhage  may  call  for  ligation  of 
the  facial,  temporal  or  even  the  external  carotid  arteries.  Careful 
cleansing  and  packing  with  iodoform  gauze  secure  excellent  results. 

TREATMENT  OF  GUNSHOT  WOUNDS  OF  THE  NECK 

These  wounds  are  always  dangerous  and  yet  in  no  other  region 
does  the  unexpected  more  frequently  happen  in  the  passage  of  a 


1 70        GUNSHOT   AND    OTHER    WOUNDS    IN    MILITARY   PRACTICE 

bullet.  The  fact  of  hairbreadth  escape  of  important  structures  is 
explainable  only  by  the  small  size  of  the  army  bullet  and  the  mobility 
of  the  structures  (Fig.  121).  The  transverse  or  oblique  track  is 
most  common.  Such  wounds  as  are  not  immediately  fatal  are 
likely  to  recover.  Sepsis  usually  has  its  origin  in  the  air  passages 
or  the  esophagus.  Injuries  to  the  trachea  give  rise  to  hemoptysis, 
emphysema  or  broncho-pneumonia.  Gangrene  of  the  esophagus 
may  occur.  Aneurism  is  not  infrequent.  Any  of  the  nerves  may 
be  injured. 


Fig.   122. — French  boy  (Hotel  Majestic)  shot  from  side  to  side  through  the  neck,  the  bullet 
passing  between  the  trachea  and  esophagus.     Tracheotomy  required  on  account  of  dyspnea. 
Leakage  of  fluids  from  an  esophageal  fistula  which  closed  in  a  few  days, 
still  in  place.      (Tlwrburn,  Brit.  Jour.  Surg.,  Jan.,  I9i5-) 


Tracheotomy  tube 


No  special  treatment  is  called  for  beyond  the  hemostasis  and 
antisepsis,  unless  occasionally  a  tracheotomy  may  be  indicated 
(Fig.  122). 


TREATMENT  OF  GUNSHOT  WOUNDS  OF  THE  SPINE 

The  treatment  of  wounds  of  the  spine  must  be  conservative;  that 
is  to  say,  that  very  rarely  will  immediate  operation  be  indicated. 
Absence  of  the  deep  reflexes  must  not  be  taken  to  indicate  complete 
rupture  of  the  cord  but  if  motion  and  sensation  do  not  improve  in 


TREATMENT  OF  GUNSHOT  WOUNDS  17I 

ten  days  a  laminectomy  may  be  performed.  If  the  laminectomy 
does  not  seem  to  restore  the  pulsation  of  the  cord  the  theca  must  be 
opened  and  the  clots  removed.  Recovery  does  not  always  take 
place  even  though  the  cord  is  not  lacerated. 

TREATMENT  OF  GUNSHOT  WOUNDS  OF  THE  ABDOMEN 

Rotter  (Berlin.  Medizin.  Clinik,  Jan.  13,  191 5)  states  as  the 
result  of  his  studies  of  this  class  of  injuries  that  the  mortality  on  the 
field  is  90  per  cent. ;  among  those  living  to  reach  the  field  hospital 
80  per  cent,  die;  of  those  reaching  the  clearing  hospitals  40  per  cent, 
die,  and  finally  those  who  reach  the  base  hospitals  recover. 

Spontaneous  cure  is  possible  only  when  the  perforation  is  small 
and  single  and  the  bowel  empty.  If  the  patient  is  seen  within 
twelve  hours  he  advises  operation  and  states  that  the  conditions  are 
so  good  in  the  German  field  hospitals  that  one  need  not  fear  sepsis 
by  reason  of  the  operation  done  there. 

From  the  other  armies  the  reports  are  not  so  favorable  to  operative 
treatment  and  most  of  the  authorities  reluctantly  admit  the  ineffi- 
ciency of  operation  in  the  field  hospitals  and  the  better,  though 
unsatisfactory,  results  of  conservative  treatment.  The  prognosis 
varies  with  the  part  of  the  digestive  tube  involved.  The  ascending 
and  descending  colon  and  the  cecum  gives  the  best  prognosis;  the 
stomach  is  not  quite  so  favorable,  and  the  perforation  of  the  trans- 
verse colon  and  small  intestine  are  most  likely  to  result  fatally. 

TREATMENT  OF  WOUNDS  OF  THE  THORAX 

The  non-perforatins:  wounds  need  only  an  antiseptic  dressing. 
Broken  ribs  will  require  adhesive  strapping. 

The  perforating  wounds  presenting  no  special  indications  of 
hemorrhage  from  the  chest  wall  are  to  be  treated  by  aseptic  occlusion. 

The  internal  mammary  or  the  intercostal  arteries  may  need  to  be 
controlled.  If  the  hemorrhage  is  visceral,  opium  and  compression 
of  the  chest  wall  by  firm  bandaging  seem  to  be  the  last^esort  in  time 
of  war.  Under  no  circumstances  is  the  wound  to  be  probed  or 
examined  with  the  finger.     Transportation  is  always  to  be  feared. 


172        GUNSHOT   AND    OTHER    WOUNDS    IN    MILITARY   PRACTICE 

In  every  way  the  patient  is  to  l)e  kept  as  quiet  as  possible.  He  must 
be  made  to  realize  the  seriousness  of  his  injury.  Paracentesis  should 
not  be  performed  in  the  case  of  hemothorax  until  the  bleeding  has 
ceased.  Thoracotomy  is  to  be  performed  if  suppuration  occurs. 
(See  Injuries  of  Thorax.) 


Fig.   123. — Fragments  of  Vickers-Maxim  i -pound  shell.      (Makins.) 


SHELL  AND  SHRAPNEL  WOUNDS 

These  wounds  constitute  a  very  large  percentage  of  the  casualties 
of  battle.  Following  the  usual  classification  they  may  be  designated 
as  contusions  or  lacerations,  much  more  frequently  the  latter. 

These  injuries  may  be  arranged  in  groups: 

I.  Large,  destructive,  mutilating  wounds,  often  resulting  in 
immediate  death.  A  whole  limb  may  be  irrevocably  damaged; 
half  the  skull  shot  away;  the  thoracic  or  abdominal  cavities  torn 
open. 


SHELL   AND    SHRAPNEL   WOUNDS 


173 


2.  A  multiplicity  of  small  wounds  penetrating  no  deeper  than  the 
fascia  and  containing  fragments  of  the  shell  or  its  contents.  There 
may  be  thirty  or  forty  such  wounds  scattered  over  the  trunk  arid 
limbs. 

3.  Surface  wounds;  the  margins  irregular;  the  skin  often  bruised  or 
burned;  no  fragments  retained. 


Fig.   124. — Shrapnel  bullets  normal  and  deformed.      (Makins.) 


4.  Penetrating  wounds  caused  by  a  single  fragment  of  shell, 
passing  right  through  the  affected  region.  The  wound  exit  is  always 
much  larger  than  wound  of  entrance.  Its  edges  are  everted,  fart  and 
muscle  tissue  often  protruding.  The  edges  of  the  entry  wound  are 
inverted  and  often  charred.  The  tissues  are  widely  destroyed,  the 
skin  presenting  a  brawny  appearance,  due  to  interstitial  hemorrhage. 

5.  A  single  penetrating  wound,  the  fragment  retained.  As  in 
the  other  cases  the  amount  of  deep  damage  is  out  of  proportion 
to  the  size  of  the  wound  entry.     That  these  projectiles  should  pro- 


174        GUNSHOT   AND    OTHER   WOUNDS    IN   iMTLITARY   PRACTICE 

duce  such  terrible  lacerations  in  many  cases  is  at  once  apparent  from 
a  study  of  their  character  (Figs.  123,  124,  125). 

Isolated  injuries  to  nerves  and  vessels  are  unknown.  Muscles, 
vessels,  nerves  and  bones  all  share  together  in  the  destruction  caused 
by  these  irregularly  shaped  missiles.  The  great  tendency  to  infec- 
tion is  not  inherent  in  the  wound  but  in  the  environment,  for  accord- 
ing to  Pannett  it  is  astonishing  how  mild  the  infection  is  in  such 


Fig.  125. — Fragments  of  shells  (two-thirds  natural  size)  removed  from  various  wounds 
received  in  naval  combat.  The  shrapnel  fired  by  the  Germans  consist  of  irregular  metallic 
fragments — not  the  round  bullets  found  in  English  shrapnel  pictured  above.  (Panneti, 
Brit.  Jour.  Surg.,  Jan.,  191S.) 


wounds  received  in  naval  warfare,  by  reason  of  the  absence  of 
earth  dust  and,  in  many  cases,  by  reason  of  a  longer  or  shorter  sea 
bath  (British  Journal  of  Surgery,  Jan.  ii,  1915). 

In  the  limbs  all  degrees  of  destruction  are  met  with,  from  absolute 
mangling  to  tearing  of  the  soft  parts  with  compound  comminuted 
fractures  of  various  degrees.  Whether  immediate  amputation  shall 
be  practised  depends  on  general  principles  referable  to  the  blood 


SHELL    AND    SHRAPNEL   WOUNDS 


175 


supply.     If  the  circulation  of  the  member  is  compromised  beyond 
hope,  amputation  should  be  performed  without  delay  (Fig.  126). 


Fig.   126.— Shrapnel  wound.     Comminuted  fracture  of  the  femur.     Frightful  mangling  of 
soft  parts.     Amputation.     {Harris,  Brit.  Jour.  Surg.,  Jan.,  1915.^ 

In  other  cases,  especiaUy  if  the  wound  is  produced  by  the  leaden 
balls  of  shrapnel,  the  limb  may  be  treated  as  in  the  ordinary  case 
of  compound  fracture  (Fig.  127). 


176        GUNSHOT   AND    OTHER    WOUNDS   IN    MILITARY   PRACTICE 

Lacerated  scalp  wounds  with  compound  fracture  of  the  vertex 
are  common. 


Fig.   127. — Fracture  of  lower  third  of  femur.     Round  shrapnel  ball  in  situ.     {Harris,  Brit. 

Jour.  Surg.,  Jan.,  igiS-) 


In  the  face,  horrible  disfigurements  result;  an  eye  may  be  de- 
stroyed; the  mouth  cavity  exposed;  the  bones  of  the  orbit,  face  or 
jaws  splintered. 


SHELL    AND   SHRAPNEL   WOUNDS 


177 


Chest  injuries  of  this  type  are  usually  fatal,  either  from  shock  or 
hemorrhage. 

Occasionally,  however,  a  fragment  of  shell  may  traverse  the 
thorax  with  a  result  no  more  serious  than  a  severe  hemothorax. 
Small  fragments  may  be  deflected  by  the  ribs  without  fracture.  A 
fragment  may  lodge  in  the  thorax  and  empyema  is  likely  to  ensue 
(Fig.  128). 


Fig.    128. — Shell   wound   of  base   of   thorax.     Empyema    and   subphrenic    abscess,   com- 
municating through  a  hole  in  diaphragm.      {Thorburn,  Brit.  Jour.  Surg.,  Jan.,  19 15-) 


In  the  abdomen  such  wounds  are  almost  universally  fatal.  If 
the  wound  is  limited  to  the  parietes,  however,  recovery  may  follow. 
In  some  such  cases  the  contusion  of  the  bowel  may  result  in  a  fecal 
fistula  (Fig.  129). 

All  these  wounds  are  to  be  treated  along  the  lines  already  dis- 
cussed in  connection  with  bullet  wounds.  In  the  matter  of  amputa- 
tion Fitz  Maurice  Kelly  calls  attention  to  the  great  advantages  of  a 


12 


lyS        GUNSHOT   AND   OTHER   WOUNDS    IN   MILITARY   PRACTICE 

simple  circular  section  of  all  tissues  at  the  same  level.     After  infec- 
tion is  passed  a  second  operation  is  done  and  flaps  formed. 


Fig.  129. — Shell  wound  perforating  abdomen.  Arrow  shows  aperture  of  entry;  the  top- 
most wound  the  exit;  the  middle  wound  marks  site  of  a  subsequent  fecal  fistula  leading  into 
the  descending  colon.     {Pannett,  Brit.  Jour.  Surg.,  Jan.,  igiS-) 


BOLO  WOUNDS 

According  to  Fojworthy  (Ft.  Wayne  Medical  Journal,  June,  1902), 
every  insurgent  in  the  Philippines  was  armed  with  a  bolo.  "This 
bolo  was  of  iron  with  a  wood  or  bone  handle  and  varied  in  shape  and 
size  from  a  sword  to  a  dagger  and  from  a  corn  knife  to  a  meat  ax. 


BOLO   WOUNDS  1 79 

It  was  generally  a  cruder  weapon  than  the  Cuban  machete,  but 
very  effective  in  close  encounters.  As  it  could  be  concealed 
beneath  the  loose  jacket,  it  was  more  serviceable  than  a  sword  or 
saber,  which  was  always  visible.  The  kries  is  a  weapon  similar  to 
the  bolo,  but  with  a  wavy  edge  like  a  Christy  bread-knife.  It  is 
often  two-edged.  The  wounds  produced  by  the  bolo  and  kries  were 
often  of  great  length  and  usually  infected. 

"Another  class  of  wounds  was  caused  by  spears  and  tomahawks, 
used  by  the  Igorrotes  and  Negrites.  The  tomahawk,  having  a 
concave  edge,  was  not  so  apt  to  glance  off  the  skull  as  an  Indian 
tomahawk.     A  blow  split  the  skull  wide  open. 

The  spears  were  often  of  bamboo,  sharpened  to  a  fine  point,  and 
their  penetrating  power  was  almost  equal  to  that  of  an  iron-tipped 
spear.  The  iron-tipped  spear  had  from  one  to  four  barbs  which 
made  an  exceedingly  ugly  penetrating  wound  and  usually  had  to  be 
cut  out.  These  w^ounds  were  always  infected  and  tetanus  fre- 
quently developed." 

FIRST  AID  ON  THE  BATTLEFIELD 

Colonel  Nicholas  Senn,  in  his  address  before  the  Lisbon  Inter- 
national Medical  Congress,  1906,  formulated  the  principles  of  first 
aid  on  the  battle  field,  and  his  conclusions  though  needing  revision 
in  the  light  of  recent  events  are  nevertheless  herewith  summarized: 

(i)  The  fate  of  the  wounded  depends  largely  upon  the  time 
and  thoroughness  with  which  first  aid  is  rendered.  This  first  aid 
for  many  reasons  cannot  be  rendered  by  the  surgeon,  but  must  be 
given  by  comrades  or  by  the  wounded  man  to  himself.  First  aid 
administered  in  this  manner  will  be  effective,  owing  to  the  aseptic 
character  of  the  chief  wounds  of  battle,  if  previous  instructions 
have  been  given.  It  is  absolutely  essential  that  the  soldier  should 
receive  this  elementary  instruction  when  he  is  taught  the  art  of  war, 
and  it  should  not  be  postponed  as  has  been  done  only  too  often  in 
the  past  until  war  clouds  make  their  appearance. 

(2)  The  first-aid  dressing  should  combine  simplicity  with  safety 
against  post-injury  infection.  It  should  be  on  the  person  of  every 
combatant  and  must  be  simple  to  be  efficient.  It  must  be  compact 
and  easy  of  application. 


l8o        GUNSHOT   AND    OTHER    WOUNDS    IN    MILIT.\RY   PRACTICE 


''The  dressing  consists  essentially  of  two  pads  of  cotton,  wrapped 
in  gauze,  and  fastened  together  by  two  stitches  and  continuous 
with  a  gauze  roller,  which  is  made  use  of  instead  of  the  triangular 
bandage  for  holding  the  dressing  in  place  and  for  immobilizing  the 
injured  part.  The  gauze  roller  should  take  the 
place  of  the  triangular  bandage  in  every  first-aid 
dressing  as  it  requires  much  less  space  and  is  more 
serviceable  as  a  means  of  fixation  and  support. 

"The  brown  iodine  spot  in  the  center  of  the  pad 
on  the  side  to  be  brought  in  contact  with  the 
wound  corresponds  with  the  location  of  the  anti- 
septic powder  incorporated  in  the  absorbent  cotton 
and  serves  as  an  infallible  guide  in  applying  the 
pad  in  the  right  place." 

(3)  The  first  aid  must  have  in  \dew  the  treat- 
ment of  shock  and  hemorrhage,  dressing  of  the 
wound,  and  immobilization  of  the  injured  part. 

The  treatment  of  shock  in  the  field  is  very  un- 
satisfactory, but,  fortunately,  shock  is  not  a  char- 
acteristic of  small-caliber  bullet  wounds.  Rest  in 
the  recumbent  position;  hypodermic  injection  of  1^ 
grain  of  morphine;  spirits  internally — these  answer 
the  most  urgent  indications. 

The  treatment  of  hemorrhage  at  the  front  must 
be  conducted  with  the  greatest  caution.     Elastic 
tremity  in  the  treat-    constriction,  if    too    ^enerallv   practised,   will   do 

ment  of  hemorrhage.  °  '  i         i  i  i  i  •    j 

{Senn.)  vastly  morc  harm  than  good.     It  should  be  applied 

only  in  exceptional  cases  and  then  by  a  competent 
member  of  the  hospital  corps  or  a  medical  officer,  who  must  make 
it  his  duty  to  send  the  case  to  the  first  dressing  station  as 
quickly  as  possible,  where  definitive  hemostasis  can  take  the  place 
of  the  constrictor.  There  are  less  harmful  means  of  hemostasis 
which  vriW  be  efficient  in  most  cases:  elevation  of  the  Hmb  (Figs. 
130,  131),  acute  flexion  of  the  joint  above  the  wound  (Figs.  132, 
133),  digital  compression  over  the  dressing — these  are  measures 
which  must  be  taught. 

Direct   treatment  of  internal  hemorrhage  of  any  of  the  large 


Fig.    130. — Eleva- 
tion   of    upper    ex- 


FIRST    AID   ON    THl-:   BATTLEFIELD  l8l 

cavities  is  cnlircl\-  out  of  the  (jueslion  at  or  near  the  firing  line.  The 
cartridge  belt,  suspenders,  or  gunstrap  can  be  used  to  the  greatest 
advantage  in  Hmiting  respiratory  and  abdominal  movements  and 
thus  secure  for  the  vascular  bleeding  organs  a  condition  of  rest, 
conducive  to  spontaneous  arrest  of  hemorrhage  (Fig.  134). 


Fig.    131. — Gunstack  for  elevation  of  the  lower  extremity.      {Senn.) 

Immobilization  is  an  essential  part  of  first-aid  treatment,  con- 
ducing to  primary  repair,  relieving  pain,  and  preventing  infection 
by  securing  the  first-aid  dressing. 

The  ideal  fixation  splint  in  such  cases  would  be  the  plaster-of- 
Paris  splint,  but  this  method  of  fixation  is  entirely  out  of  the  question 
on  the  firing  line  and  must  be  reserved  for  the  dressing  station  of 
field  hospital.  This  first-aid  fixation  must  be  extemporized. 
The  sound  leg  may  serve  as  a  splint  for  the  wounded  one  which  is 
held  in  place  by  belt,  gunstrap,  handkerchief,  etc.  The  rifle, 
bayonet,  and  saber    are    always    available  as    spHnts    (Figs.   135, 

136,  137)- 
A  fractured  humerus  may  be  splinted  to  the  side  of  the  body. 


1 82        GUNSHOT   AND   OTHER   WOUNDS   IN   MILITARY   PRACTICE 

A  well-padded  bayonet  will  meet  the  indications  in  fracture  of  the 
forearm.  The  wire  netting  cut  in  the  shape  corresponding  to  the 
fixation  of  the  different  fractures  of  the  limbs  should  be  carried  to 
the  front  by  the  sanitary  corps  in  sufficient  quantities  to  meet  the 
expected  requirement.  Splints  made  of  this  material,  well-padded, 
will  answer  an  excellent  purpose  as  first-aid  fixation,  as  they  can  be 


Fig.   132. — Forced  flexion  of  the  elbow-joint  in  arresting  hemorrhage  from  the  brachial  in 

that  region.     (Senn.) 


molded  into  shape  and  can  be  used  subsequently  to  strengthen  the 
plaster  bandage  at  the  dressing  station. 

(4)  The  first-dressing  station  is  the  most  important  place  for 
skilled  aid.  This  primary  depot  of  the  wounded  should  be  estab- 
lished in  a  sheltered  place  as  near  as  possible  to  the  firing  line, 
protected  as  much  as  possible  against  the  fire  of  the  enemy. 

(5)  Probing  of  recent  gunshot  wounds  must  be  prohibited  by  the 


FIRST   AID    ON   THE  BATTLEFIELD 


183 


most  stringent  rules.     Under  no  circumstances  should  attempts  be 
made  to  remove  bullets  until  this  can  be  done  under  strict  aseptic 


Fig.    133. — Forced  flexion  of  the  knee  in  hemorrhage  from  the  popliteal  region.      (Senn-) 

precautions  in  the  hospital,  and  then  only  in  those  cases  in  which 
such  operation  is  clearly  indicated  and  the  exact  location  of  the 
bullet  has  been  determined  by  palpation 
through  the  intact  skin  or  by  the  use  of  the 
''X-ray." 

(6)  The  surgeon's  most  important  duties 
at  the  first-dressing  station  are: 

(a)  Inspection  of  first-aid  dressing.  If  it 
is  in  its  proper  place,  label  to  this  effect  that 
it  may  not  be  unnecessarily  removed  at  the 
hospital.  If  defective,  it  must  be  renewed 
or  more  securely  fastened. 

(b)  Application  of  plaster  splints  to  the 
fractured  limbs;  the  wire-netting  splints  are 
cut  into  strips  and  incorporated  in  the  plaster- 
of-Paris  dressing. 

(c)  Emergency  operations.  The  operative 
treatment  of  gunshot  wounds  must  be  limited 
to  the  most  urgent  cases.  The  definitive 
arrest  of  hemorrhage — of  dangerous  external 
or  internal  hemorrhage — stands  pre-eminent       ^  t,  r      • 

'^  ^     '■  .  Fig.    134 . — Perforating 

in  the  list  of  emergency  operations.     Iodized    wound  of  chest,  aseptic  tam- 
catgut  is  the  proper  ligature  material  for  field   p°nnade    and  immobiiiza- 

^  r-      X-  o  tion  by  Circular  compression. 

service.  (Senn.) 


1 84        GUNSHOT    AND   OTHER    WOUNDS   IN    MILITARY   PRACTICE 

Tntra-crania]  and  iiitra-tlioracic  hemorrhage  should  not  be  inter- 
fered with  outside  of  a  well-equipped  hospital.  Dangerous  intra- 
abdominal   hemorrhage    calls   for   prompt   operative   interference. 


:^^ 


Fig.   135. — Saber  splint  for  leg  and  thigh.     (Senn.) 

Abdominal  section  under  such  circumstances,  in  a  tent,  may  con- 
tribute much  in  lessening  the  mortality  from  hemorrhage  by  a 
resort  to  ligature,  suture,  or  aseptic  tamponade. 


Fig.    136. — Gun  splint.      (Senn.) 


B}-  pursuing  this  aggressive  course,  some  lives  may  be  saved  by 
prompt  interference  which  would  be  lost  by  the  let-alone  treatment. 


Fig.    137. — Stick  and  blanket  splint.    (Senn.) 

Wounds  of  the  larynx  and  trachea  which  have  given  rise  to  respira- 
tory difficulties,  either  from  emphysema  or  hemorrhage,  call  for  an 
immediate  tracheotomv. 


FIRST    AH)    ON   THE  BATTLEFIELD  1 85 

Resection,  as  a  primary  operation  for  penetrating  gunshot  wounds 
of  the  joints,  is  obsolete. 

Amputation  must  be  reserved  for  cases  in  whicli  a  limb  has  become 
mangled  by  a  cannon  ball  or  fragment  of  shell  or  in  which  the 
fracture  is  complicated  by  division  of  the  principal  blood-vessels  and 
nerves. 

Laparotomy  in  the  iield,  for  gunshot  wounds  of  the  abdomen, 
with  a  view  of  finding  and  suturing  perforations  of  the  gastro- 
intestinal canal,  has  not  yielded  in  practice  the  anticipated  results, 
and  hence  must  be  restricted  to  exceptional  cases. 

Clinical  experience  has  shown  that  in  a  fair  percentage  of  cases 
penetrating  wounds  at  and  above  the  level  of  the  umbilicus,  inflicted 
in  the  antero-posterior  direction,  do  not  implicate  the  gastro- 
intestinal canal,  and  in  such  cases  conservative  treatment  yields 
better  results  than  operative.  On  the  other  hand,  in  w^ounds  involv- 
ing the  small  intestine  area,  more  especially  when  the  bullet  takes 
an  oblique  or  transverse  course,  we  may  confidently  expect  to  find 
from  three  to  fifteen  perforations,  and  it  is  in  this  class  of  cases  in 
which  immediate  laparotomy  offers  the  only  chance  of  saving  life. 

(7)  The  surgeon's  field  case  should  be  light,  compact,  and  the 
instruments  wrapped  in  a  canvas  roll,  so  that  instruments  and 
envelope  can  be  quickly  sterilized  in  boiling  soda  solution. 


CHAPTER  XIII 
GUNSHOT  WOUNDS  IN  CIVIL  PRACTICE 

The  projectiles  of  the  ordinary  fire-arms  of  civil  life  differ  from 
those  used  in  warfare,  in  that  they  are  composed  of  soft  lead,  are 
easily  deformed,  are  of  slight  initial  velocity,  and  are  usually  fired 
at  short  range. 

The  revolver  and  pistol,  flobert  and  shot-gun  produce  the  wounds 
most  frequently  seen. 

Of  the  shot-gun  it  may  be  said  that  the  wounds  which  it  produces 
are  very  likely  to  be  either  greatly  destructive  or  comparatively 
harmless.  At  close  range  the  charge,  acting  as  a  single  body,  lacer- 
ates and  shreds  the  tissues;  at  long  range  a  number  of  small  per- 
forations are  made. 

The  dangerous  wounds,  then,  have  all  the  characteristics  of  lacera- 
tions and  demand  the  treatment  of  lacerated  wounds  in  general. 
It  must  always  be  assumed  that  foreign  bodies  have  been  carried 
into  the  tissues  and  that  these  wounds  are  therefore  infected. 

It  is  the  bullet  wound  of  the  revolver,  however,  which  it  is  most 
practical  to  consider.  To  a  limited  extent,  its  pathology  is  similar 
to  that  of  the  army  bullet,  and  it  is  unnecessary  to  state  again  the 
effect  of  a  bullet  upon  the  various  tissues.  It  is  expedient  to  con- 
sider at  once,  with  especial  reference  to  treatment,  the  bullet 
wounds  of  certain  localities. 

But  let  it  be  emphasized  in  this  connection  that  the  course  of  the 
bullet  can  never  be  accurately  determined. 

Always  be  on  the  alert  for  the  unexpected  and  insist,  however 
simple  the  wound  may  appear  to  be,  that  the  patient  be  kept  under 
close  surveillance.  The  wound  may  seem  to  be  a  flesh  wound  of  the 
thigh,  for  example,  and  may  be  dismissed  as  such;  later,  and  too  late 
perhaps,  it  may  be  discovered  that  the  peritoneal  cavity  was  involved. 
And  this  happened  to  a  boy  of  ten  who  was  brought  to  the  City 

1 86 


BULLET  WOUNDS  OF  THE  HEAD  1 87 

Hospital  with  not  the  sHghtest  symptoms  to  indicate  any  serious 
injury.  Too  late,  it  was  found  that  the  intestine  was  perforated 
in  many  places. 

Again,  however  well  assured  we  may  be  that  no  serious  damage 
has  been  done  we  shall  nevertheless  watch  for  signs  of  hemorrhage 
or  beginning  infection. 

We  must  remember,  too,  that  infection  may  develop  late. 

A  man  of  thirty-five  was  brought  in  with  a  38  bullet  wound  in  the 
region  of  the  knee.  His  limb  was  swelling  rapidly  and  he  was  im- 
mediately prepared  for  operation. 

The  bullet  had  bored  through  the  upper  end  of  the  tibia  from  in 
front  backward  and  lodged  in  the  popliteal  space.  A  counter  open- 
ing was  made  from  behind,  the  bullet  extracted.  The  hemorrhage 
indicated  an  arterial  wound  and  following  the  track  of  the  bullet, 
the  anterior  tibial  was  found  divided  near  its  point  of  origin.  It  was 
ligated,  the  posterior  opening  in  the  tibia  located  and  a  strip  of  gauze 
saturated  with  iodine  passed  through  the  hole  in  the  bone.  Drain- 
age left  in  both  anterior  and  posterior  openings. 

For  a  week  the  patient  did  well  and  was  thought  to  be  entirely 
out  of  danger.  At  that  time  however  his  temperature  rose  and  very 
shortly  there  were  signs  of  suppuration  and,  in  spite  of  free  drainage, 
gangrene  developed  and  the  limb  was  amputated  well  above  the 
knee.  But  the  flaps  refused  to  heal  and,  grave  symptoms  of  general, 
sepsis  supervened.  He  died  three  weeks  after  his  injury  and  the 
postmortem  revealed  a  septic  thrombus  along  the  whole  length  of 
the  femoral  vein. 

WOUNDS  OF  THE  HEAD 

The  region  of  the  brain  is  usually  wounded  in  attempts  at  suicide, 
and  it  is  the  right  temple  or  forehead  which  is  most  frequently  se- 
lected. The  vertex,  postero-lateral,  and  occipital  regions  are  seldom 
wounded  and  only  then  as  a  result  of  accident  or  assault. 

As  medico-legal  questions  are  often  involved  in  these  cases,  it  is  a 
wise  practice  to  make  careful  and  systematic  examinations.  Learn 
as  much  as  possible  about  the  character  of  the  fire-arm,  the  nature 
of  the  projectile,  the  position  of  the  patient  at  the  time  of  injury. 


1 88  GUNSHOT   WOUNDS    IN   CIVIL   PRACTICE 

Examine  the  ears  and  nose  for  blood,  inspect  the  mouth,  examine  the 
head  for  a  wound  of  exit,  or  see  if  the  bullet  can  be  located  beneath 
the  scalp. 

Next  examine  the  wound  itself,  but  not  until  the  field  and  wound 
have  been  sterilized.  Begin  the  disinfection  by  sha\dng  the  scalp 
about  the  wound.  Wash  with  soap  and  water  and  then  with  alcohol 
or  bichloride. 

Enlarge  the  wound  by  a  cross  incision,  if  necessary,  and  wipe  out 
with  sterile  gauze,  removing  all  forms  of  foreign  bodies. 

Finally  examine  the  skull.  If  you  find  a  mere  depression  without 
penetration,  it  is  sufficient  to  pack  the  opening  with  sterile  gauze, 
and  bandage.  Later  the  bullet  may  be  located  with  the  "X-ray" 
and  removed,  if  it  becomes  troublesome.  If  the  bullet  is  visible  and 
removable  without  much  difficulty,  it  is  better  to  take  it  out 
at  once. 

If  the  ball  has  penetrated  the  entire  thickness  of  the  skull  and 
lodged  within  the  cavity,  the  size  of  the  orifice  will  be  some  index  as 
to  its  probable  depth;  if  the  orifice  is  large,  it  argues  for  close  range 
and  deep  lodgment.  If  the  opening  is  small,  comparatively  speak- 
ing, it  is  likely  that  the  ball  has  not  penetrated  deeply.  Note  the 
direction  of  the  fissures.  If  the  base  is  involved  the  prognosis  is 
always  serious.  Note  the  condition  of  the  dura:  it  may  be  lacerated 
and  the  brain  tissues  may  exude.  If  such  is  the  case,  the  bullet  is 
obviously  in  the  brain,  but  its  exact  location  must  remain  a  matter 
of  doubt.  It  is  not  expedient  to  explore  it;  it  is  not  even  advisable 
to  attempt  to  disinfect  the  cerebral  wound. 

It  is  sufficient  to  remove  all  fragments  of  bone  and  debris  and 
wipe  the  wound  dry  with  sterile  gauze.  On  these  two  points,  how- 
ever, there  may  be  some  difference  of  opinion.  The  American  Text- 
book of  Surgery  insists  upon  the  value  of  disinfection  of  the  entire 
cerebral  track  of  the  bullet  and  of  through-and-through  drainage 
under  certain  circumstances;  also  upon  the  advisability  of  attempting 
to  locate  the  bullet  by  the  aluminium  gravity  probe,  and  to  remove  it. 
Still  it  may  be  said  that  the  general  practitioner  has  done  his  duty 
and  done  it  well  if  he  has  cleansed  the  skull  and  dural  wounds  and 
controlled  the  hemorrhage.  (For  further  details  of  treatments,  see 
Urgent  Craniectomy.) 


TREPHINING    THE    SPINAL   CANAL 


GUNSHOT  WOUNDS  OF  THE  SPINE 


189 


A  man  was  brought  into  the  City  Hospital  shot  in  the  back  with 
a  38  revolver.  Except  that  he  was  paralyzed  from  his  hips  down 
and  without  control  of  his  bladder  and  bowels,  his  condition  was 
good.  This  positive  primary  paralysis  pointed  to  grave  injury  to 
the  cord.  At  the  operation  it  was  found  that  the  bullet  had  smashed 
into  the  spinal  canal  and  there  lodged,  completely  obliterating  in 


Fig.   138. — Complete  division  of  spinal  cord;  bullet  retained. 


its  course  a  considerable  segment  of  the  spinal  cord  (Fig.  138). 
Suture  of  the  cord  was  out  of  the  question,  so  the  poor  fellow— a  man 
of  great  vitality — was  condemned  to  linger  in  living  death  for  many 
weeks. 

Happily  not  all  cases  of  gunshot  wound  involving  the  cord  are 
beyond  relief.  Whenever  the  symptoms  point  to  severe  injury  of  the 
cord — ^whenever  there  are  notable  disturbances  of  sensation  and 
motion^and  improvement  fails  to  take  place  shortly,  it  is  bad 
practice  to  delay.  It  is  indicated  to  cut  down  upon  the  spine,  re- 
move a  spinous  process,  trephine  into  the  canal,  and  cautiously  cut 
away   the  arches.     It  may  develop   that   the  symptoms  are    due 


ipo  GUNSHOT   WOUNDS    IN   CR'IL   PRACTICE 

merely  to  pressure  of  fragments  of  bone  which  are  to  be  removed. 
If  after  gunshot  wounds  of  the  spine  there  are  no  cord  symptoms 
or  if  they  are  mild  and  tend  to  improve,  it  is  better  not  to  operate. 
The  smaller  the  projectile  the  less  the  Hkelihood  that  operation  will 
be  required.  Without  some  positive  indication  in  the  cord,  there- 
fore, aseptic  occlusion  is  the  treatment  to  pursue.  Probing  is  all  the 
more  perilous  because  infection  may  be  carried  directly  to  the  spinal 
meninges. 

GUNSHOT  WOUNDS  OF  THE  FACE 

These  may  result  from  shots  into  the  mouth  with  'suicidal  intent. 
Small  bullets  may  remain  imbedded  in  the  hard  palate  or  posterior 
pharyngeal  wall.  The  instinctive  tilting  of  the  head  backward 
gives  the  bullet  a  characteristic  course  through  the  hard  palate  or 
the  root  of  the  nose,  and,  owing  to  the  involvement  of  the  base  of 
the  brain,  such  wounds  are  deadly,  except  with  quite  small  fire- 
arms. 

In  other  cases  there  are  grave  comminuted  fractures  of  either  jaw. 
Sometimes  there  are  powder  burns  and  disintegrations  suggestive 
of  explosions. 

The  chief  dangers  in  cases  not  immediately  fatal  are  from  inter- 
ference with  respiration  and  from  hemorrhage.  These  wounds  are 
also  predisposed  to  infection,  and  as  a  result  of  sepsis  secondary 
hemorrhage  is  not  infrequent.  Paralysis  of  the  facial  nerve  may 
occur.  The  salivary  glands  or  their  ducts  may  be  injured  and  give 
rise  to  a  troublesome  dribbling  of  saliva.  Marked  interference  with 
respiration  may  call  for  immediate  tracheotomy. 

Arteries  may  need  to  be  ligated  and  ligation  may  be  difficult  owing 
to  their  relation  to  the  bones.  The  oozing,  always  marked,  is  to  be 
controlled  by  pressure.  The  natural  contour  is  to  be  restored  as 
much  as  possible  after  a  thorough  cleansing,  and  the  wound  cavities 
packed  with  iodoform  gauze.  A  young  man  was  brought  to  the  City 
Hospital  with  gunshot  wound  of  the  face,  the  range  so  close  the  skin 
was  powder  burned.  He  was  bleeding  profusely  from  the  mouth. 
It  was  found  that  the  bullet,  a  38,  had  entered  the  left  upper  jaw, 
passed  through  it  into  the  nasopharynx,  carrying  away  part  of  the 
soft  palate  and  still  ranging  slightly  downward  had  lodged  in  the 


TREATMENT   OF    GUNSHOT    OF    CHEST  I9I 

middle  of  the  neck  of  the  opposite  side.  It  was  located  about  the 
depth  of  the  sterno  mastoid.  An  incision  under  local  anesthesia  was 
made  and  a  dissection  carried  down  to  the  bullet.  It  was  grasped 
with  forceps  but  slipped  away  and  on  further  attempts  to  seize  it, 
was  pushed  back  into  the  pharynx  and  coughed  out. 

The  wound  in  the  jaw  w^as  injected  with  peroxide  which  escaped 
through  the  mouth. 

Finally  a  slip  of  sterile  gauze  w^as  carried  through  the  channel  in 
the  jaw,  one  end  of  the  strip  left  in  contact  with  the  lacerated  tissues 
of  the  soft  palate,  the  outer  end  projecting  from  the  wound.  Some 
oozing  persisted  for  twenty-four  hours.  On  the  second  day  the  strip 
was  removed  and  the  wound  injected  with  w^eak  peroxide  solution. 
No  infection  arose  and  he  recovered  rapidly,  apparently  none  the 
worse  for  the  injury. 

GUNSHOT  WOUNDS  OF  THE  THORAX 

Gunshot  wounds  of  the  thorax  do  not  differ  from  other  w^ounds  in 
this  region  except  in  their  graver  prognosis.  (See  page  no,  Wounds 
of  Thorax,  and  page  149,  Military  Practice.)  Such  as  involve  the 
great  vessels  at  the  root  of  the  lungs  and  most  of  those  which  involve 
the  heart  are  not  even  of  interest  from  a  standpoint  of  treatment 
because  so  rapidly  fatal  as  to  preclude  intervention. 

Such  wounds  as  are  not  obviously  fatal,  whether  they  involve  the 
pleura  and  lungs  or  the  pericardium  and  heart,  present  three  sources 
of  danger:  hemorrhage,  asphyxia,  and  infection.  These  are  the 
three  conditions  which  determine  the  line  of  treatment,  and  which 
have  already  been  discussed  under  the  head  of  Wounds  of  the 
Thorax. 

Aside  from  these  symptoms  of  urgency,  the  treatment  must  be 
conservative  and  expectant — quite  different  from  gunshot  wounds 
of  the  abdomen. 

Begin  by  covering  the  wound  with  an  aseptic  compress  and  then 
carefully  disinfect  the  field.  Finally  cleanse  the  wound  itself  and 
dress  antiseptically.     Avoid  probing  or  other  explorations. 

Transportation  must  also  be  avoided,  for  there  can  be  no  doubt 
that  it  is  often  disastrous.  In  the  country,  where  ambulances  are 
out  of  the  question,  the  nearest  shelter  is  the  best. 


ig2  GUNSirOT   WOUNDS    TN   CIVIL   PI^ACTICE 

If  it  is  evident,  finally,  that  the  hemorrhage  is  increasing,  as  indi- 
cated by  the  symptoms  and  i)hysical  signs,  conservatism  is  no  longer 
rational  and  the  wounded  lung  should  be  exposed  and  the  tear 
repaired.  In  the  event  a  tear  is  found  in  a  i)u]monary  vein  a 
ligature  must  be  })laced  on  either  side  of  the  tear.  Recovery  may 
follow  without  lung  complications. 

KUtner,  of  Leipsic,  proposes  in  the  future  when  dealing  with  these 
wounds  to  evacuate  the  extravasated  blood  if  it  is  not  promptly  ab- 
sorbed, suturing  the  pleura  without  drainage.  In  the  case  of  an 
already  collapsed  lung  it  does  not  appear  that  there  would  be  in- 
creased danger  ojieraling  without  the  aid  of  a  Sauerbruch  cabinet. 

BULLKT  WOUNDS  OF  THP:  ABDOMEN 

With  reference  to  prognosis  and  treatment,  these  wounds  fall  into 
three  clinical  groups:  those  which  are  ol^viously  penetrating  and  ac- 
companied by  grave  visceral  lesions;  those  which  are  doubtful  both 
as  to  penetration  and  visceral  injury;  and  those  which  are  probably 
benign. 

(A)  One  concludes  that  a  certain  wound  is  grave  not  from  ob- 
serving the  escape  of  gas  and  fecal  matter,  or  hemorrhage  from  the 
wound,  for  these  are  too  infrequent  to  be  relied  upon,  but  from  the 
general  condition,  which  alone  is  of  sufficient  significance.  The 
pulse  is  small  and  rapid;  the  face  is  drawn  and  pale;  the  belly  wall 
is  distended  and  resistant  to  the  least  pressure;  dullness  of  the  iliac 
fossa  and  flanks  develops  and  there  may  be  vomiting  of  stomach 
contents  or  of  blood. 

The  persistence  of  these  symptoms  for  the  first  two  or  three  hours 
is  sufficient  to  dispel  any  illusion  of  the  more  sanguine  that  the  case 
is  not  dangerous. 

There  is  but  one  thing  to  do,  operate  as  soon  as  possible. 

This  is  a  principle  so  definitely  established  that  the  citation  of  a 
long  list  of  eminent  authorities  is  unnecessary:  a  rational  doctrine 
that  all  may  accept. 

There  are  contingencies  of  time  and  place,  of  septic  environment 
which  would  insure  that  the  operation  itself  would  likely  be  fatal, 
but  those  conditions  are  very  exceptional  in  civil  practice  with  the 


TREATMENT  OF  GUNSHOT  OF  ABDOMEN  1 93 

doctor  who  has  the  "savoir-faire."  An  exceptional  condition  docs 
not  alter  the  principle,  and  he  who  does  not  act  at  once,  must  incur 
the  reproach  of  having  refused  the  wounded  the  best  resource  of 
safety. 

There  is  another  consideration.  One  may  not  be  called  to  see  the 
case  until  after  two  or  three  days  have  elapsed  and  may  then  en- 
counter one  of  two  eventualities:  one  almost  certain,  the  other 
unlikely. 

In  the  first,  there  are  the  signs  of  general  peritonitis.  Under  these 
circumstances,  again,  the  rule  is  to  operate,  though  only  as  a  forlorn 
hope. 

On  the  other  hand,  it  may  be  that  despite  the  apparent  gravity 
of  the  wounds,  the  pulse  is  good,  there  is  no  vomiting,  the  abdomen 
is  not  tender,  there  has  been  a  passage  of  flatus  or  a  movement  of 
the  bowels.  Al  though  we  know  these  appearances  are  often  deceitful, 
that  it  may  be  only  the  lull  which  precedes  the  storm,  yet  we  are 
perfectly  justified,  under  these  circumstances,  in  maintaining  an 
''armed  expectancy."  Under  such  circumstances,  control  peris- 
talsis with  a  little  morphia,  impose  an  absolute  quiet  and  absence 
of  food,  and  in  the  meantime  have  the  patient  under  vigilant 
surveillance. 

Fysche  reports  a  case  of  abdominal  gunshot  wound,  which  shows 
the  value  of  drainage  and  which  might  be  taken  as  an  indication  of 
the  course  to  pursue  in  certain  desperate  cases,  where,  for  example, 
the  circumstances  of  time  or  place,  the  condition  of  the  patient,  or 
the  isolation  and  lack  of  skill  of  the  operator  precluded  a  more 
rational  and  definite  procedure. 

A  boy  of  fourteen  was  shot  through  the  abdomen  at  close  range 
with  a  large-caliber  revolver.  The  bullet  entered  just  to  the  in- 
side of  the  right  anterior-superior  spine.  There  were  all  the  signs 
of  shock  and  internal  hemorrhage.  The  abdomen  was  opened 
with  immediate  escape  of  blood  and  fecal  matter.  The  first  por- 
tion of  the  small  intestine  examined  revealed  a  perforating  wound. 
This  and  two  other  wounds  were  repaired,  but  the  boy's  condition 
called  for  haste  and  a  hurried  examination  developed  seven  more 
perforations  of  gut  and  mesentery  along  the  6  feet  exposed.  The 
abdominal  incision  was  closed  with  through-and-through  sutures 
13 


194  GUNSHOT   WOUNDS    IN   CIVIL   PRACTICE 

with  a  large  deeply  placed  drainage  wick  in  the  lower  angle.  He 
was  freely  stimulated  and  given  large  enemas  of  normal  salt  solution. 
The  drainage  was  removed  on  the  second  day  and  from  the  opening 
there  was  a  free  fecal  discharge.  On  the  third  day  his  bowels 
moved^ naturally.  Thereafter  the  fistula  closed  rapidly  and  in  a 
month  he  seemed  quite  well.     (Montreal  Med.  Jour.,  May,  1909). 

(B)  The  case  is  one  of  doubtful  penetration  and  therefore  doubt- 
ful visceral  injury. 

You  are  called  immediately.  You  find  nothing  more  than  a 
bullet  wound  in  some  part  of  the  anterior  abdominal  wall.  The 
pulse  is  good,  the  abdomen  is  neither  rigid  nor  tender,  and  there  is 
no  other  indication  worth  noting. 

Now,  what  are  you  to  do?  Wait  several  hours  watching  for  some 
indication?  But  this  is  a  dangerous  formula,  subject  to  various 
interpretations,  for,  as  Lejars  asks,  what  shall  be  regarded  as  the 
first  "indication" — ^the  weaker  pulse,  the  tympanites,  the  altered 
facies?     But  these  are  the  signs  of  beginning  peritonitis. 

It  is  better,  as  Brown,  of  St.  Louis,  and  many  others  have  so  defi- 
nitely determined,  to  answer  the  question  resolutely  in  these  terms: 
prepare  at  once  to  operate;  determine  whether  the  wound  is  a  pene- 
trating one  or  not,  and  if  so,  proceed  with  the  laparotomy — pro- 
vided, of  course,  that  the  situation  is  such  that  it  can  be  done  with- 
out very  grave  danger  from  the  operation  itself.  It  may  develop 
that  the  operation  is  not  necessary,  but  it  will  very  much  more  fre- 
quently become  evident  that  it  is  indispensable. 

Admit  that  these  urgent  laparotomies  are  difficult,  that  they  strain 
every  resource  of  emergency  antisepsis  and  surgical  skill,  that  the 
perforations  are  often  multiple,  that  one  never  knows  just  what  he 
must  meet.  Admit  that  some  recover  from  these  wounds  without 
operation,  but  are  we  authorized  by  that  to  expect  in  another  case 
so  fortunate  a  denouement?  Admit  that  the  patient  has  several 
chances  of  recovery  without  operation  perhaps,  but  let  us  remem- 
ber we  have  no  means  of  calculating  such  chances  even  in  the  more 
favorable  cases,  and  certainly  the  chance  of  an  exceptional  proc- 
ess cannot  give  more  hope  than  an  early,  regulated,  and  aseptic 
intervention. 


TREATMENT  OF  GUNSHOT  OF  ABDOMEN  1 95 

It  is  prudence  which  commands  operation.  As  Lejars  says,  this 
seems  the  wisest  course: 

Prepare  for  a  laparotomy.  Begin  by  cleansing  the  field]oropera- 
tion  and  then  the  wound,  which  is  enlarged,  cutting  from  above 
downward,  layer  by  layer.  If  the  peritoneum  is  found  uninjured, 
repair  the  incision  carefully,  first  trimming  the  devitalized  tissues 
away;  under  these  circumstances,  one  may  safely  prognosticate  a 
recovery. 

If  you  find  the  peritoneum  perforated,  slightly  enlarge  that  wound 
also,  that  you  may  get  some  idea  as  to  the  conditions:  a  flow  of 
blood,  bile,  intestinal  contents,  or  urine  may  indicate  what  one  may 
expect.  But  the  fact  alone  of  perforation  of  the  peritoneum  is  an 
indication  to  open  the  abdomen  in  the  middle  line — to  do  a  median 
laparotomy. 

The  median  incision  will  l)e  above  or  below  the  umbiHcus,  de- 
pending upon  the  level  of  the  bullet  wound  (see  Laparotomy  for 
Traumatism). 

(C)  There  are,  finally,  as  Lejars  points  out,  certain  bullet  wounds 
which,  even  though  penetrating,  may  be  regarded  as  unlikely  to 
have  produced  serious  results.  These  are  such  as  are  produced  by 
pistols  in  which  the  bullet  is  quite  small  and  impelled  by  an  insig- 
nificant charge  of  powder,  so  that  its  force  is  practically  spent  in 
traversing  the  abdominal  wall. 

And  even  though  the  digestive  tube  should  be  wounded,  the 
opening  is  not  large  enough  for  the  contents  to  escape,  for  the  mucous 
membrane  acts  as  a  plug  and  repair  quickly  takes  place. 

In  such  a  case,  there  being  no  doubt  as  to  the  facts,  it  is  perhaps 
wiser  not  to  operate,  but  to  treat  by  aseptic  occlusion.  Neverthe- 
less it  is  the  part  of  prudence,  however  sanguine  of  the  outcome,  to 
keep  the  case  under  close  watch  for  some  days. 

GUNSHOT  WOUNDS  OF  THE  JOINTS 

The  knee,  which  is  the  joint  most  frequently  wounded,  may  serve 
as  a  type.  Suppose  it  is  wounded  by  the  discharge  of  a  fowling- 
piece,  a  not  uncommon  accident.     The  character  of  these  wounds 


196  GUNSHOT   WOUNDS    IN   CI\^IL   PRACTICE 

is  variable.  It  may  be  that  only  a  few  shots  at  long  range  have 
penetrated  the  joint,  or  it  may  happen  that  the  whole  load  has  torn 
its  way  into  the  joint  structure.  But  whatever  the  condition,  no 
active  intervention  is  called  for  if  the  case  is  seen  at  once. 

Cover  the  wound  with  sterile  gauze,  provide  a  temporary  splint, 
and  supervise  the  transportation.  Once  under  shelter,  proceed  to 
carry  out  a  methodical  cleansing  and  examination.  Cleanse  the 
field  first  and  then  the  wound  itself. 

If  the  wound  was  received  at  long  range  and  probably  only  a 
few  shots  have  penetrated  the  joint  cavity,  the  careful  cleansing, 
antiseptic  dressing,  and  subsequent  immobilization  will  be  all  that 
is  required  to  bring  about  an  uninterrupted  recovery  without  loss  of 
function. 

If  the  wound  was  received  at  close  range  and  the  joint  is  freely 
penetrated  by  the  shot,  which  have  carried  in  shreds  of  clothing  and 
other  foreign  particles,  the  treatment  is  quite  different. 

Suppose  the  joint  is  swollen,  dark  blood  oozes  out,  and  the  cavity 
is  exposed  through  lacerated  wounds:  in  such  a  case  conservatism 
will  not  cure.  Prepare  to  operate  immediately.  Open  the  joint 
and  with  hot  normal  salt  solution  freely  flush  out  the  shot,  frag- 
ments of  bone  and  cartilage,  blood  clots  and  other  debris.  Do  not 
be  sparing  of  time  and  patience.  Trim  away  the  lacerated  tissues. 
If  satisfied  with  the  cleansing,  suture  the  deeper  layers  over  the  joint 
so  as  to  close  it  completely,  and  drain  only  the  superficial  wound; 
otherwise,  drain  the  joint  cavity  as  well.  Apply  an  antiseptic 
dressing  and  immobilize,  and  expect  a  good  result. 

The  situation  is  again  different  if  the  case  has  been  treated  first  by 
the  uninstructed.  The  wound  is  seen  some  time  after  injury  and 
found  covered  with  dirty  cloths,  or  a  handkerchief,  the  worse  for 
usage,  is  stuffed  into  the  wound.  No  covering  at  all  is  always  better 
than  anything  less  clean  than  a  sterile  dressing. 

The  treatment  is  the  same  as  before — in  every  way  as  rigorous 
and  systematic — but  there  are  not  the  same  certainties  by  any 
means  that  it  will  head  off  sepsis.  You  cleanse,  drain,  immobilize, 
and  watch.  You  watch  for  beginning  infection,  which  for  that 
matter  may  develop  in  the  simpler  cases  if  the  cleansing  is  not 
complete.     Fever,  pain,  swelling  of  the  joint,  all  rapidly  increasing^ 


TREATMENT  OF  GUNSHOT  OF  HAND  1 97 

are  the  signs  of  beginning  infection  and  suppuration  and  call  for 
immediate  action.  It  is  indicated  to  open  the  joint  and  drain. 
(See  page  440,  Arthrotomy.) 

Bullet  wounds  produce  similar  lesions,  although  usually  they  are 
of  the  milder  type.  Hemarthrosis  indicates  injury  to  bone  as  well 
as  soft  parts.  Sometimes  these  wounds  occur  with  scarcely  any 
injury  to  the  joint  structure,  the  bullet  lodging  in  the  epiphysis. 
In  the  milder  cases,  wherever  the  bullet  may  be,  it  is  better  merely  to 
cleanse  and  immobilize,  and  at  a  later  date,  if  necessary,  the  ball 
may  be  removed.  If,  however,  the  hemarthrosis  is  voluminous, 
it  is  better  to  open  the  joint  at  once  and  clean  out  the  cavity  and, 
by  a  happy  chance,  the  bullet  may  be  found  and  extracted.  (See 
also  gunslwt  wounds  of  joints  in  military  practice,  and  compound 
dislocations.) 

GUNSHOT  WOUND  OF  HAND 

A  pawnbroker,  examining  a  revolver  brought  in  for  a  loan  and 
which  was  supposed  not  to  be  loaded,  was  shot  through  the  hand. 
The  32  bullet  passed  betw^een  the  heads  of  the  third  and  fourth 
metacarpals,  splintering  the  fourth  in  some  degree.  The  tissues 
were  powder-stained  along  the  track  of  the  bullet  and  the  wound 
bled  very  freely. 

The  wound  of  entrance  in  the  palm  was  jagged;  the  wound  of  exit 
smooth.  The  wounds  were  cleansed  and  a  slender  forceps  passed 
through  the  hand,  a  piece  of  gauze  attached  and  pulled  into  place 
for  through-and-through  drainage  by  withdrawing  the  forceps.  The 
bleeding  stopped,  but  later  began  again,  soaking  the  bandages. 
Syringing  the  wound  with  peroxide  and  packing  with  gauze  served 
to  check  the  bleeding  for  a  few  hours.  This  intermittent  hemor- 
rhage persisted  for  two  days. 

The  hand  was  soaked  twice  daily  for  a  half-hour  in  hot  normal  salt 
solution;  the  swelling  and  pain  rapidly  subsided  and  after  three  or 
four  days  the  wound  began  to  heal  without  the  least  evidence  of  in- 
fection. The  ring  finger  w^as  stiff  and  painful  for  some  time,  but 
under  massage  and  passive  motion  gradually  regained  its  use. 

Injury  to  the  tendons  constitutes  one  of  the  chief  complications 
of   gunshot   wounds   of   the   hand.     Free   trimming   away   of   the 


1 98  GUNSHOT    WOUNDS    IN    CR^IL   PRACTICE 

shattered  tissues,  free  drainage  and  free  use  of  hot  normal  salt  solu- 
tion seem  best  calculated  to  promote  repair  in  this  class  of  wounds. 

SUPERFICIAL   W^OUNDS    FROM   FOWLING-PIECE 

A  farm  hand,  charged  with  trespass,  was  brought  to  the  county 
jail  sorely  wounded.  Two  charges  of  bird-shot  had  caught  him  on 
the  fly  and  peppered  his  back,  buttocks,  and  the  posterior  surfaces 
of  thigh  and  calves.  Evading  his  pursuers,  aided  by  the  darkness, 
he  had  reached  his  cabin  exhausted  and,  without  changing  his  bloody 
clothes,  lay  thus  unattended  for  two  days,  when  he  was  discovered 
and  arrested.  By  this  time  infection  had  set  in.  His  buttocks 
and  calves,  particularly,  where  the  shot  were  thickest,  were 
swollen  and  inflamed.  Many  of  the  shot  had  carried  shreds  of 
clothing  into  the  tissue:  each  was  a  focus  of  suppuration;  none  had 
penetrated  beyond  the  skin.  The  whole  injured  area  was  cleansed, 
first  with  soap  and  water,  and  then  rubbed  vigorously  with  peroxide 
of  hydrogen;  the  more  superficial  of  the  shot  were  picked  out,  and 
finally  the  inflamed  surfaces  were  smeared  with  Reclus'  ointment  and 
covered  with  sheets  of  gauze  held  in  place  by  adhesive  strips.  The 
relief  from  pain  was  great.  In  three  or  four  daily  seances  the  shot 
were  all  picked  out  and  the  inflammation  practically  gone. 

WOUNDS    FROM    TOY    PISTOLS    AND    BLANK    CARTRIDGES 

Two  things  are  noteworthy  in  connection  with  these  wounds: 
first,  the  surprising  power  of  penetration  of  cartridges  supposed  to 
be  harmless;  and,  second,  the  great  danger  of  a  tetanus  infection. 
The  'Svad"  may  be  buried  out  of  sight  in  the  tissues,  it  may  entirely 
perforate  the  hand,  or  it  may  produce  a  superficial  laceration. 
As  a  rule,  the  hemorrhage  is  insignificant,  which  may  in  a  measure 
account  for  the  development  of  infection,  since  bleeding  is  nature's 
means  of  disinfection. 

These  wounds  often  present  the  appearance  of  punctured  wounds, 
which,  more  than  others,  are  likely  to  furnish  conditions  favorable  to 
the  growth  of  the  tetanus  baciUus. 

It  may  be  that  the  disposition  of  the  wad  is  such  that  the  wound  is 
in  a  manner  stopped  up,  so  that  oxygen  cannot  reach  the  recesses 


PREVENTION    OF   TETANUS  I99 

where  Ihe  bacillus  finds  its  ludgmenL.  It  is  true  LliaL  leLaims  de- 
velops in  only  a  small  percentage  of  cases,  but  one  can  never  foretell 
positively  what  such  a  wound  may  do. 

It  is  the  duty  of  every  doctor  to  warn  his  clientele  of  the  danger  of 
these  "Fourth  of  July"  injuries. 

Every  case  is  to  be  treated  as  if  lock-jaw  is  not  merely  a  remote 
possibiUty,  but  a  probability.  Free  cleansing  and  douching  with 
peroxide  of  hydrogen  is  indicated. 

Luckett  says  (American  Journal  of  Surgery,  July,  1906):  "These 
wounds  should  be  freely  incised,  particularly  if  not  seen  on  the  first 
day  of  the  injury,  and  thoroughly  curetted  with  a  small  sharp  spoon 
until  all  the  small  pieces  of  wad,  the  unburned  grains  of  powder,  and 
all  the  dirt  have  been  removed.  If  the  wad  has  entered  a  m^etacarpal 
space  a  counter-incision  must  be  made  for  through-and-through 
drainage.  Having  cleaned  the  wound  as  thoroughly  as  can  be  done 
mechanically,  we  now  resort  to  chemicals  and  irrigate  with  some 
mild  antiseptic.  After  next  drying  the  wound  thoroughly,  the  entire 
cavity  should  be  swabbed  out  with  one  of  the  following,  named  in 
order  of  choice: 

"i.  Pure  carbolic  acid  followed  by  alcohol. 

"2.  Twenty  per  cent,  tincture  of  iodine  (made  by  dissolving  iodine 
crystals,  20  parts,  in  ether  and  alcohol,  each  50  parts). 

"3.  Plain  tincture  iodine. 

"The  wound  should  now  be  packed  with  moist  iodoform  gauze. 
A  wet  dressing  is  then  applied,  to  be  changed  daily.  Permission 
should  be  obtained  for  a  prophylactic  injection  of  an ti tetanic  serum. 
Ten  c.c.  are  intra-muscularly  injected  in  the  buttocks  or  thigh,  under 
thorough  antiseptic  precautions." 

Antitetanic  powder  may  be  appHed  to  the  wound,  as  advised  by 
Calmette.  Experiments  conducted  by  Joseph  McFarland,  of  Phila- 
delphia, corroborate  Calmette's  statements  as  to  the  prophylactic 
value  of  this  substance.  By  its  use  McFarland  was  able  to  protect 
from  infection  animals  which  he  had  inoculated  with  the  tetanus 
bacillus. 


CHAPTER  XIV 
FRACTURES  OF  THE  EXTREMITIES 

Definitions. — A  fracture  is  a  solution  of  the  continuity  of  bone 
due  to  traumatism. 

A  simple  fracture  has  a  single  line  of  solution  and  there  is  no 
lesion  of  the  soft  parts. 

A  multiple  fracture  has  more  than  one  line  of  solution  of  con- 
tinuity in  the  same  bone  or  several  bones. 

A  comminuted  fracture  has  so  many  lines  of  solution  running  into 
each  other  that  the  bone  is  in  fragments  or  splinters. 

A  complete  fracture  involves  the  whole  thickness  of  the  bone.  It 
may  be  transverse,  longitudinal,  oblique,  dentate  or  comminuted. 

In  an  incomplete  fracture,  the  line  of  solution  does  not  involve  the 
whole  thickness  or  extent  of  the  bone.  It  may  be  a  fissure,  ''a  green 
stick,"  a  depression  or  a  separation  of  an  apophysis. 

A  subcutaneous  fracture  has  no  communication  with  the  surface. 

An  open  or  compound  fracture  has  a  communication  with  the  sur- 
face, has  an  accompanying  solution  of  continuity  of  the  skin  and  the 
subjacent  soft  parts. 

A  spontaneous  fracture  is  produced  by  an  insignificant  traumatism 
and  is  usually  pathological,  due  to  disease  of  the  bone. 

An  ununited  fracture  is  one  in  which  bony  union  has  not  occurred 
at  the  usual  time. 

Gunshot  fractures  are  those  produced  by  projectiles  (see  Gunshot 
Wounds). 

Fractures  of  the  extremities  are  emergencies,  often  of  the  first- 
class;  their  reduction  sometimes  becomes  equivalent  to  a  major 
operation.  But  it  cannot  be  said  that  these  cases  are  always  treated 
well.  As  Senn  says,  ''Bad  results  following  fractures  have  been  the 
tombstones  that  have  marked  the  termination  of  an  otherwise  suc- 
cessful professional  career  of  many  an  ill-fated,  unlucky,  disappointed 
practitioner." 

200 


DIAGNOSIS    OF   FRACTURE  20I 

Malpractice  suits  more  frequently  follow  this  class  of  cases,  per- 
haps, than  any  other,  which  is  an  indication  that  somewhere  there  is 
a  fault.  Doubtless  it  is  the  fear  of  a  damage  suit  that  often  makes 
a  basis  for  it  and  in  this  way:  The  doctor,  in  order  that  he  may  have 
testimony  as  to  his  skill,  treats  the  case  in  the  sterotyped,  and 
routine  way;  he  gets  a  bad  result.  Had  he  used  his  better  judg- 
ment, given  his  common  sense  rein  and  risked  the  reproach  of  being 
an  innovator,  the  result  would  have  been  different. 

Every  case  must  be  studied  and  treated  on  its  own  merits,  with 
due  regard,  of  course,  to  certain  general  principles.  To  begin  with, 
the  prognosis  should  always  be  guarded  in  some  degree.  As  King 
says  (St.  Paul  Medical  Journal,  August,  1906):  ''Optimism  as  to 
the  final  outcome  on  the  part  of  the  physician  is  a  mistake.  Take 
the  patient  into  your  confidence,  let  him  anticipate  the  certainty 
of  some  permanent  defect,  so  that  in  the  end  an  imperfect  result  will 
not  reflect  so  much  upon  your  skill  and  will  tend  to  minimize  mal- 
practice suits.  And  how  very  rarely  indeed  can  the  result  be  per- 
fect. With  the  very  best  treatment,  there  will  nearly  always  re- 
main as  the  best  outcome  some  slight  weakness,  or  limitation  of 
motion,  or  ache,  or  pain — ^at  least  a  callus  as  a  'lasting  memorial.'" 

The  diagnosis  of  these  fractures  is  usually  easy  in  the  large  sense, 
as  King  says,  but  after  all  difficult  as  a  whole,  for  no  eye  can  see  the 
injury  wrought  to  the  softer  tissues.  In  many  cases  the  position 
will  indicate  at  once  that  there  is  a  fracture,  but  one  must  endeavor 
to  learn  much  more — the  possible  associated  injuries  to  joints, 
muscles,  blood  vessels,  and  nerves.  To  be  able  to  do  this  necessitates 
a  fairly  accurate  knowledge  of  anatomy  to  begin  with,  aided  by 
systematic  examinations,  and  on  this  foundation  skill  grows  with 
experience. 

The  diagnosis  of  fracture  in  the  bones  of  the  extremities  is  based 
on  several  factors:  (a)  history  of  the  case,  (b)  deformity,  (c)  abnormal 
mobility,  (d)  pain  and  loss  of  function,  (e)  crepitus,  (f)  X-ray 
examination. 

(a)  It  is  essential  to  know  how  the  accident  occurred.  Frequently 
in  the  absence  of  definite  symptoms,  the  diagnosis  must  rest  upon 
the  history.  For  example,  in  a  case  of  a  hip-joint  injury  in  an  elderly 
person  presenting  loss  of  function  and  some  pain  but  no  other  symp- 


2  02  FRACTURES    OF   THE    EXTREMITIES 

toms,  a  diagnosis  of  impacted  fracture  should  be  made  if  it  is  learned 
the  patient  fell  striking  the  hip. 

(b)  Deformity  includes  changes  in  the  relations  or  dimensions  of 
the  bones  and  the  appearance  of  the  limb.  The  two  hmbs  must 
always  be  compared.  It  must  be  determined  that  there  has  been 
no  previous  injury  to  cause  the  deformity.  When  both  ends  of  a 
bone  are  accessible  to  touch,  it  may  be  readily  measured  and  com- 
pared with  its  opposite.  In  the  case  of  the  humerus,  it  is  necessary 
to  measure  from  the  acromion;  in  the  case  of  the  femur,  from  the 
ilium.  The  position  which  the  fragments  assume  may  be  due  to  the 
direction  of  the  force  or  the  action  of  the  muscles. 

(c)  Preternatural  mobility  implies  movement  in  unnatural  situa- 
tions or  in  unnatural  degree  or  cUrection.  As  one  of  the  cardinal 
signs  of  fracture,  it  has  hitherto  been  assigned  too  much  importance. 
Its  presence  indicates  fracture,  but  its  absence  indicates  nothing. 
We  all  know  that  in  impacted  fracture,  there  is  no  abnormal  mobility. 
In  fractures  of  the  bones  of  the  tarsus  and  carpus,  in  epiphyseal 
fracture,  in  any  fracture  where  the  fragments  are  small  or  deeply 
placed,  it  may  be  impossible  to  discover  movement  without  a  manipu- 
lation which  may  be  distinctly  injurious.  In  the  case  of  fractures 
near  joints,  it  may  be  impossible  to  determine  whether  the  move- 
ment is  in  the  joint  or  near  it. 

The  fact  is  that  in  most  cases  where  abnormal  mobility  is 
present,  the  fracture  may  be  readily  diagnosed  without  reference 
to  this  sign. 

(d)  Crepitus  is  the  almost  constant  accompaniment  of  abnormal 
mobility  and  is  the  grating  produced  by  the  friction  of  the  two 
fragments.  It  is  pathognomonic,  but  must  not  be  sought  for  too 
vigorously.  It  is  absent  in  impacted  fracture,  and  to  break  up  an 
impacted  fracture,  testing  for  crepitus,  may  be  a  calamity.  Crepitus 
may  sometimes  be  heard  with  the  phonendoscope  and  not  with  the 
ear. 

(e)  Pain  and  loss  of  function  go  together  since  the  pain  is  usually 
the  cause  of  the  loss  of  function.  Both  are  present  in  nearly  all 
fractures,  but  often  occur  in  as  great  degree  with  contusions. 

The  amount  of  pain  varies  with  the  location,  but  is  nearly  always 
aggravated  by  movements  or  pressure.     Taken  in  connection  with 


DIAGNOSIS   OF   FRACTURES  203 

the  history  of  the  case,  it  is  a  valuable  diagnostic  aid.     The  presence 
of  pain  may  call  for  anesthesia  before  the  diagnosis  can  be  completed. 

Stimson  has  recently  emphasized  the  significance  of  pain  in  the 
diagnosis  of  fracture,  and  indicated  the  manner  in  which  it  may  be 
interpreted.  Crepitus  and  abnormal  mobihty  are,  to  his  mind,  of 
less  importance  than  pain  as  a  diagnostic  aid. 

The  search  for  pain  in  all  doubtful  cases  should  be  systematic. 
Begin  hrst  with  local  pressure  over  the  suspected  area  with  the  tip 
of  the  finger  or  with  the  rubber  end  of  a  lead-pencil.  There  are 
definite  lines  of  tenderness  to  be  discovered  in  many  of  the  fractures 
about  joints.  For  example;  in  Colles'  fracture  this  line  can  be  plainly 
traced  across  the  radius  just  above  the  wrist;  in  fracture  of  the  ex- 
ternal condyle  of  the  humerus,  along  the  external  condylar  ridge  just 
above  the  elbow;  and  in  fracture  of  the  surgical  neck  of  the  humerus 
along  the  front  or  outer  side  of  the  bone. 

Next  test  the  character  of  pain  elicited  by  cautious  movement  of 
the  limb.  Increased  muscular  tension  thus  produced  awakens  in- 
creased pain  at  the  site  of  the  fracture,  and  the  patient  may  be  able 
to  indicate  the  exact  location  of  the  lesion.  The  effort  on  the  part 
of  the  patient  to  produce  certain  movements  is  helpful. 

Finally,  indirect  pressure  may  be  employed:  thus,  in  transverse 
fracture  of  the  tibia,  pressure  upward  on  the  foot  exaggerates  the 
pain  markedly;  and  in  the  same  manner,  pressure  upward  at  the 
elbow,  may  assist  in  locating  the  fracture  in  the  shaft  of  the  humerus. 
Stimson  notes  the  important  exception,  that  in  the  case  of  fracture 
of  the  neck  of  the  femur  forcible  pressure  upward  often  fails  to  cause 
pain. 

In  the  case  of  fracture  of  one  of  the  bones  of  the  forearm  or  leg, 
squeezing  the  two  bones  together  will  generally  help  the  patient  to 
locate  his  trouble. 

(f)  The  X-ray  cannot  be  ordinarily  available  in  general  practice, 
although  of  the  greatest  assistance  in  cases  of  doubt.  Without  its 
use  many  fractures  in  the  region  of  joints  will  be  diagnosed  as  some- 
thing else.  Bloodgood  particularly  emphasizes  its  value  (Pro- 
gressive Medicine,  Dec,  1906),  believing  that  the  doctor  who  neglects 
the  aid  of  the  Rontgen  picture,  when  he  is  able  to  obtain  it,  will 
have  much  to  regret.     There  is  no  danger  that  its  employment 


204  FRACTURES  OF  THE  EXTREMITIES 

will  blunt  the  diagnostic  sense,  unless,  as  is  often  done  in  hospitals, 
it  is  used  to  the  exclusion  of  other  aids.  The  X-ray  has  at  least 
modified  our  notions  as  to  what  constitutes  a  perfect  result  in  the 
treatment  of  a  fracture.  Wherever  the  X-ray  picture  is  used  to 
back  up  a  claim  of  malpractice  by  reason  of  inaccurate  apposition 
of  fractured  bone,  we  must  insist  that  restoration  of  form  and  func- 
tion constitutes  a  perfect  result  surgically,  whatever  discrepancies 
the  Rontgen  picture  may  reveal. 

The  treatment  implies  a  reposition  and  an  immobilization  that 
the  bones  may  unite  in  their  normal  relations.  It  has  that  ob- 
jective, but  has  also  another  which  is  not  necessarily  a  concomitant 
of  the  first.  The  bones  must  unite  without  deformity  but  there 
also  must  be  restoration  of  the  limb's  functions.  Union  in  good 
position,  then,  is  only  one  of  the  means  to  a  larger  end.  It  is  better 
to  say  that  the  treatment  includes  reduction,  immobilization,  and 
mobilization. 

In  making  reduction,  violence  must  be  avoided.  Gentle  but  per- 
sistent effort  is  always  better  than  rude  haste  in  overcoming  the 
resistance  of  muscles  and  ligaments,  which  is  usually  the  chief 
obstacle  to  reposition.  The  line  of  traction  must  be  adapted  to  the 
muscular  action.  Traction  must  usually  be  accompanied  by  counter- 
traction  and  local  manipulation  of  the  broken  ends. 

In  making  traction  it  should  be  made  directly,  if  possible,  on  the 
bone  involved,  without  the  intervention  of  a  joint.  For  example,  in 
reducing  the  humerus  the  traction  should  be  applied  above  the  elbow 
joint.  Often  an  anesthesia  is  necessary  to  relax  the  muscles,  and  if 
anesthesia  was  necessary  to  complete  the  diagnosis,  everything 
should  have  been  prepared  previously  for  the  treatment  so  that 
only  a  single  anesthesia  is  necessary  for  diagnosis,  reduction,  and 
dressing. 

In  the  cases  of  suspected  fracture  in  the  vicinity  of  a  joint,  it  is 
not  always  best  to  hurry  the  reduction;  often  it  is  better  to  wait  a 
day  or  so  and  try  to  reduce  the  swelling,  for  the  swelling  aggravates 
the  difficulties  which  are  always  great  in  the  differential  diagnosis 
about  the  joint;  and,  if  flexion  is  required,  as  in  the  case  of 
certain  fractures  above  the  elbow,  the  pressure  may  shut  off  the 
circulation. 


TREATMENT  OF  FRACTURES  205 

So  far  as  the  shaft  of  the  long  bones  are  concerned,  however,  the 
formula  should  be  im^nediate  reduction  and  fixation.  That  the  re- 
duction has  been  complete  is  attested  by  the  appearances  of  the 
limb,  by  the  absence  of  any  irregularities  to  the  touch,  and  by  the 
coincidence  of  its  measurements  with  those  of  the  sound  limb. 
These  comparative  measurements  should  be  a  matter  of  routine 
practice. 

Warbasse  says  (J.  A.  M.  A.,  March  13,  1909),  "the  sooner  a 
fracture  is  reduced  and  held  immovable,  the  less  will  be  the  swelling 
and  the  more  satisfactory  the  result.  There  is  a  prevalent  notion 
of  waiting  until  the  'traumatic  reaction  has  subsided.'  This  ancient 
phrase  rolls  off  the  tongue  sonorously  and  sounds  important,  but 
is  to  be  reverently  laid  aside.  Traumatic  reaction  is  going  on  all 
the  time  as  long  as  the  bones  are  out  of  place  or  so  long  as  they  are 
movable.  If  we  can  effect  immobilization  soon  enough,  the  swelling 
will  not  come  up."  This  is  doubtless  true  in  most  cases,  yet  it  is 
to  be  remembered  that  in  spite  of  reduction  of  the  bones,  lacerated 
muscles  and  ruptured  vessels  may  continue  for  some  time,  in  some 
cases,  to  pour  their  exudate  into  the  tissues  to  augment  the  swelling. 
This  idea,  however,  pertains  more  to  the  mode  of  dressing  and 
does  not  refute  the  doctrine  of  immediate  reduction. 

hnmobilization  is  a  phase  of  treatment  raising  many  questions 
in  dispute.  In  what  manner  shall  it  be  applied  and  for  how  long? 
Or,  as  Championniere  insists,  may  it  not  in  many  cases  be  dispensed 
with  entirely?  For  he  believes  that  absolute  fixation  of  the  frag- 
ments is  not  the  condition  most  favorable  to  the  processes  of  repair. 
A  certain  amount  of  movement  is  necessary  to  the  vitality  of  the 
bone,  and  therefore  movements  and  massage  represent  the  chief 
elements  of  his  treatment.  That  it  is  the  best  treatment  for  frac- 
tures about  joints  no  one  will  deny,  even  though  unwilling  to  dis- 
pense with  fixation  in  other  fractures  of  the  long  bones. 

As  to  the  manner  in  which  fixation  is  to  be  attained,  let  it  be  said 
briefly  that  the  simplest  effective  dressing  is  the  best.  Its  elabo- 
rateness will  depend  upon  the  tendency  for  the  displacement  to  re- 
cur, and  this  tendency  must  be  measured  by  the  degree  of  obliquity 
of  the  fracture  and  the  action  of  the  muscles.  Sometimes  the  tend- 
ency to  recurrence  is  an  indication  of   imperfect  coaptation.     In 


2o6  FRACTURES    OF   THE   EXTREMITIES 

one  case,  then,  only  a  light  retaining  splint  is  necessary  and  in 
another  it  must  indeed  be  firm  and  strong. 

At  the  present  time  there  can  be  no  question  but  that  plaster  of 
Paris  is  the  dressing  of  choice.  At  any  rate,  it  will  render  the  best 
service  to  the  general  practitioner  who  must  rely  on  his  own  re- 
sources in  fashioning  splints.  Ready-made  splints  are  an  abomina- 
tion. There  are  other  plastic  materials  that  are  often  useful,  and 
in  lieu  of  all  these  materials  the  splint  may  be  cut  into  forms  to 
suit  the  case  from  boards,  etc.,  and  applied  well  padded.  (See 
page  48.) 

Walsham  formulates  the  principles  which  must  regulate  the  use 
of  splints  in  any  case. 

1.  The  splints  must  be  well  padded. 

2.  Pressure  must  not  be  made  over  the  points  of  bones. 

3.  Strapping  or  bandages  must  not  be  put  on  too  tightly. 

4.  Circular  constriction  of  the  limb  must  be  avoided. 

5.  The  splints,  if  possible,  should  reach  beyond  the  joint  above 

and  below  the  fracture. 

6.  The  patient  should  be  seen  within  twenty-four  hours  after 

the  splint  is  applied  for  the  bandage  may  become  too  tight. 

7.  The  splints  should  not  be  needlessly  disturbed — that  is  to  say, 

if  the  patient  is  comfortable  and  the  limb  in  good  condition. 

8.  Spasm  of  the  muscles  is  to  be  overcome  by  steady  extension. 

9.  The  part  below  the  fracture  should  be  bandaged,  or  at  least 

raised,  to  prevent  swelling  and  edema. 

The  first  immobilization  will  continue  till  there  is  no  tendency  to 
spontaneous  recurrence  of  the  displacement,  which  will  vary  in 
different  cases.  After  this  time  a  dressing  must  be  used  which  is 
easily  changed,  and  daily  massage  must  be  instituted.  Complete 
and  continuous  fixation  through  a  long  period  is  distinctly  bad 
practice  and  most  especially  whenever  a  joint  is  involved. 

Rossi  has  shown  (Wiener  Medical  Presse,  Jan.,  1902)  that  the 
amount  of  new  cartilage  formation  is  proportional  to  the  amount  of 
movement  permitted  and  is  found  in  the  greatest  amount  in  fractures 
treated  by  massage,  and  is  explained  by  the  greater  formation  of  new 
blood  vessels  and  the  consequent  more  active  circulation  and  ab- 
sorption of  effusion. 


TREATMENT   OF   FRACTURES  207 

You  will  ordinarily,  therefore,  proceed  in  something  after  this 
manner:  you  will  carry  out  a  systematic  inspection  before  handling 
the  part,  you  will  observe  any  deviation  of  the  hand  or  foot  from  the 
normal  axis  of  the  member  and  compare  the  injured  with  the  un- 
injured side.  In  a  large  number  of  cases  this  inspection  will  be 
sufficient  to  diagnose  the  case. 

Measurements  are  of  great  value  in  many  cases  and  must  not  be 
overlooked  as  a  diagnostic  aid.  In  the  absence  of  deformity  or 
shortening  you  may  proceed  next  to  palpate  the  affected  region  in 
order  to  determine  the  degree  of  displacement  and  other  char- 
acters of  the  fracture. 

Manipulation  may  occasionally  be  required  to  elicit  crepitus  and 
preternatural  mobility  but  certainly  should  not  be  considered  a 
routine  procedure.  In  any  event  handle  the  injured  limb  gently, 
never  forgetting  that  the  least  haste  or  carelessness  may  greatly 
aggravate  the  displacement  and  the  traumatism  to  the  soft  tissues 
or  change  a  simple  into  a  compound  fracture,  not  to  speak  of  in- 
creased shock  or  suffering  to  the  patient. 

Finally,  having  determined  as  nearly  as  possible  the  conditions 
present,  you  will  assemble  the  dressings  suitable  to  the  case.  Once 
these  are  all  prepared,  administer  the  anesthetic.  A  full  relaxa- 
tion is  essential  for  an  easy  reduction  but  as  the  anesthesia  pro- 
ceeds the  injured  limb  must  be  w^atched  by  an  assistant  lest  in  the 
stage  of  excitement  the  patient  do  himself  an  added  hurt.  The 
anesthesia  also  favors  a  more  detailed  diagnosis  and  a  better  deter- 
mination of  the  minutiae  of  treatment.  In  a  few  days  the  part  should 
be  skiagraphed  and  if  the  position  of  the  fragments  is  good,  the  limb 
well  immobilized  you  may  consider  that  a  good  union  is  in  sight. 

Finally  the  question  of  operative  treatment  is  to  be  considered. 
Whatever  advantage  plating  may  possess  it  cannot  be  the  method 
of  choice  with  the  general  practitioner.  The  open  treatment, 
therefore,  will  be  reserved  strictly  for  those  cases  in  which  either 
reduction  or  fixation  cannot  be  otherwise  accomplished. 

First  aid  to  those  disabled  with  fractured  limbs  is  in  civil  practice 
more  frequently  given  by  others  than  the  doctor.  It  is  desirable, 
however,  whenever  possible,  that  he  should  direct  the  transporta- 
tion and  the  preliminary  treatment. 


2o8  FRACTURES    OF   THE    EXTREMITIES 

The  utmost  care  must  be  practised  in  lifting  and  handling  the 
broken  limb,  lest  the  injuries  be  augmented  and  a  simple  fracture 
converted  into  a  compound. 

If  fracture  is  merely  suspected,  it  must  be  assumed  to  be  present. 
The  limb  must  never  be  lifted  by  the  foot  or  hand  but  must  be 
lifted  as  a  whole,  resting  upon  the  palms  of  the  hand.  Two  at- 
tendants are  always  better  than  one  in  handling  a  broken  leg.  If 
the  deformity  is  quite  obvious  even  to  the  unpractised,  an  effort 
should  be  made  tow^ard  reduction  before  applying  temporary  splints, 
this  with  a  view  to  preventing  further  injury  to  the  soft  parts. 

The  limb  is  seized  by  an  attendant  at  each  end  and  gentle  and 
steady  traction  made  in  the  direction  of  its  axis.  If  this  does  not 
succeed,  the  attendants  must  not  persist  in  the  effort.  It  must  be 
left  for  the  surgeon. 

If  the  fracture  is  compound,  with  severe  hemorrhage,  the  clothing 
must  be  removed.  Otherwise  this  is  not  necessary.  In  removing 
the  trousers  or  a  coat,  for  example,  the  sound  limb  is  uncovered  first 
and  then,  very  gently,  the  injured  one.  It  is  better  to  cut  the  cloth- 
ing or  rip  along  a  seam. 

A  splint  is  next  improvised  from  whatever  may  be  first  at  hand,  a 
thin  board,  laths,  an  umbrella,  or  the  branch  of  a  tree.  The  splint 
is  padded,  or  the  limb  wrapped  with  whatever  presents  itself,  a 
blanket  or  anything  to  prevent  undue  pressure,  and  then  is  fastened 
on  the  limb  by  a  cord,  or  belt,  or  suspenders,  etc.,  and  finally  the 
injured  leg  is  bound  to  the  sound  leg,  the  injured  arm  to  the  side  of 
the  chest  or  carried  in  a  sling. 

The  limb  thus  temporarily  immobilized,  the  patient  is  ready  to  be 
moved. 

To  lift  the  patient  with  the  greatest  safety  in  the  case  of  a  broken 
leg,  for  example,  one  attendant  standing  on  the  sound  side,  places 
his  arms  under  the  body  of  the  patient,  who  in  the  meantime  locks 
his  arms  about  the  attendant's  neck.  A  second  attendant,  standing 
on  the  same  side,  places  one  hand  under  the  body,  one  under  the 
sound  limb,  while  a  third  attendant,  facing  the  others,  supports 
the  broken  limb.  At  his  word  of  command,  all  lift.  This  careful- 
ness must,  not  be  relaxed. 

If  a  litter  is  available,  or  one  can  be  improvised,  it  is  placed  parallel 


FRACTURES    OF   THE   ARM  209 

with  the  patient,  its  feet  at  his  head,  so  that  without  any  incon- 
venience the  patient  may  be  laid  upon  it. 

FRACTURES  OF  THE  HUMERUS 

Certain  points  of  anatomy  apply  to  nearly  all  fractures  of  the  arm, 
and  are  useful  in  diagnosis  and  reduction.  Recall  the  relations  of 
the  humeral  head  to  the  acromial  and  coracoid  processes;  the  loca- 
tion of  the  greater  tuberosity,  the  internal  and  external  condyles; 
the  attachments  of  several  muscles,  particularly  the  deltoid,  biceps, 
and  triceps;  the  relations  of  the  musculo-spiral  nerve.  Remember 
that  in  the  normal  relations  a  line  dropped  from  the  tip  of  the 
acromion  to  the  external  condyle  will  touch  the  greater  tuberosity. 

Nor  must  one  forget  the  location  of  the  great  vessels  on  the  inner 
side  of  the  arm,  the  proximity  of  the  brachial  plexus  in  the  axillary 
space  and  the  intimate  relations  of  the  ulnar  nerve  to  the  internal 
condyle. 

All  these  matters  must  be  present  in  the  imagination  as  the  in- 
jured arm  is  inspected. 

The  musculo-spiral  groove  is  a  line  of  least  resistance  and  deter- 
mines many  of  the  spiral  fractures  of  the  shaft. 

The  age  of  the  patient  is  of  great  importance  in  determining  the 
nature  of  the  fracture  at  the  extremities.  The  difficulties  of  reduc- 
tion and  fixation  determine  largely  by  muscular  action  and  accord- 
ingly the  musculature  must  be  kept  well  in  mind. 

The  symptoms,  the  deformities,  the  complications,  the  treatment 
all  vary,  depending  on  the  part  of  the  humerus  involved;  there- 
fore the  shaft  and  the  two  extremities  must  be  studied  separately. 

FRACTURE    OF    THE    SHAFT    OF    THE   HUMERUS 

Direct  or  indirect  violence,  a  fall  on  the  elbow  or  wrist,  a  twist,  or 
muscular  contraction  may  produce  fracture  of  the  humeral  shaft 
which  for  the  present  purpose  is  considered  as  extending  from  the 
attachments  of  the  deltoid  to  the  upper  level  of  the  condyles  (Fig. 

139). 

The  line  of  fracture  may  be  transverse,  oblique,  or  spiral,  de- 
pending on  the  nature  of  the  violence.     Thus  a  blow  will  more  likely 
14 


2IO 


PRACTURES  OF  THE  EXTREAnXIES 


produce  a  transverse;  a  fall  on  the  elbow,  an  oblique;  a  twist  of  the 
arm,  a  spiral  fracture  of  the  shaft. 

On  inspection  the  broken  arm  is  usually  found  to  be  considerably 


Fig.    139. — Iracture  of  the  shaft  of  the  huir.erus. 


swollen;  the  deformity  marked,  only  when  the  patient  Ues  down; 
pain,  preternatural  mobility  and  crepitation  are  easily  elicited. 
There  is  usually  shortening  as  compared  with  the  sound  side,  meas- 


TREATMENT   OF   FRACTURES    OF   THE    AR.M 


211 


uring  from  the  tip  of  the  acromion  to  the  external  condyle  and, 
normally,  this  line  lies  over  the  greater  tuberosity  (Fig.  140). 


Fig.  140. — Testing  the  humerus  for  shortening.     Measuring  from  the  acromion  to  the 

external  condyle. 


The  treatment  will  depend  on  the  degree  of  displacement.     If 
displacement  is  absent  apply  well-padded  splints,  one  internal  ex- 


212 


FRACTURES  OF  THE  EXTREMITIES 


Fig.  141. 


The  patient  is  seated;  bandage  the  injured  member  from  the  wrist  to  about  3  inches 
above  the  elbow;  protect  the  axilla  with  absorbent  cotton;  flex  the  forearm  at  a  right  angle 
and  maintain  in  that  position  in  a  sling.  Pass  a  band  under  the  axilla  and  fasten  it  to  some- 
thing (a  hook  in  the  wall),  so  that  the  shoulder  is  slightly  lifted.  That  is  the  counter- 
extension. 

Another  band  crosses  the  forearm  just  below  the  bend  of  the  elbow  and  to  it  is  attached 
a  weight,  say  of  2  K.  G.,  that  is  the  extension.  Give  the  apparatus  a  little  time  and  it  will 
effect  a  reduction  as  the  muscles  tire.    Employ  this  interval  to  prepare  the  fixation  dressing. 

Cut  out  sixteen  strips  of  crinoline,  each  about  i  yard  long,  and  wide  enough  to  cover  the 
arm  at  its  thickest  part.  Lay  these  strips  one  upon  the  other,  and  fasten  them  together; 
and  from  the  sheet  thus  formed,  cut  a  deep  scallop  out  of  either  end — -at  the  lower  end  45  to 
50  cm.  and  at  the  upper  end  15  to  20  cm.  deep.  Of  the  yokes  thus  formed,  one  will  fit  into 
the  axilla  and  the  other  into  the  bend  of  the  elbow,  while  the  intermediate  portion  forms  an 
internal  splint  for  the  arm. 

Soak  the  cloth  in  liquid  plaster  and  apply  it  in  the  manner  indicated,  molding  it  carefully 
to  the  arm.  The  two  upper  bands  overlap  the  shoulder  and  the  two  lower  ones  are  wound 
spirally  around  the  arm  to  the  wrist.  In  this  way  the  shoulder  and  wrist  are  immobilized. 
In  the  menatime  the  extension  and  counter-extension  are  not  disturbed  until  the  plaster  split 
is  fully  hardened.     The  dressing  may  be  further  secured  by  a  few  turns  about  the  chest. 


TREATMENT  OF  FRACTURES  OF  THE  ARM  213 

tending  from  the  axilla  to  the  bend  of  the  flexed  elbow  the  other  ex- 
ternal from  the  acromion,  below  the  elbow.  These  splints  are  held 
in  place  by  adhesive  strips  and  the  whole  firmly  bandaged. 

If,  on  the  other  hand,  the  displacement  is  conspicuous,  it  may  be 
difficult  to  reduce,  difficult  to  hold.  A  number  of  procedures  are 
available;  the  patient  may  be  anesthetized,  the  fracture  reduced  by 
strong  traction,  the  patient's  shoulder  then  brought  well  over  the 
edge  of  the  table,  the  extremity  bandaged  with  glazed  cotton  and  a 
plaster  roller  applied,  including  the  wrist  and  shoulder.  The  pa- 
tient must  stay  in  bed.  Instead  of  the  plaster  roller,  plaster  splints 
may  be  applied  on  the  same  principle  as  the  wooden  splints  de- 
scribed above. 

Hennequin's  dressing  is  strongly  recommended  by  Lejars.  Its 
purpose  is  to  reduce  the  fracture  without  anesthesia  and  to  maintain 
the  reduction  until  an  internal  splint  is  applied  (Fig.  141). 

Union  requires  from  six  to  eight  weeks;  failure  to  unite  is  usually 
due  to  the  interposition  of  the  soft  parts.  The  importance  of  the 
musculo-spiral  nerve  in  this  connection  must  never  be  forgotten. 
Paralysis  of  this  nerve  occurs  in  about  8  per  cent,  of  such  fractures; 
it  may  be  immediate  or  remote,  depending  on  whether  the  nerve  is 
itself  injured  by  the  traumatism  or  whether  it  is  caught  in  the  scar 
tissue.  The  recognition  of  this  injury  is  imperative.  Inclusion  of 
the  soft  parts  which  cannot  be  remedied  calls  for  an  open  operation. 

FRACTURE   OF  THE  UPPER  END   OF  THE  HUMERUS 

These  injuries  often  ofifer  the  very  greatest  difficulties  in  diagnosis. 
Such  cases  for  the  most  part  present  themselves  with  swollen,  painful, 
and  contused  shoulders,  perhaps  deformed,  and  functionless.  You 
ask  yourself:  is  it  only  a  severely  bruised  joint;  is  it  a  dislocation  or  a 
fracture  of  the  surgical  neck,  or  perhaps  both;  or  is  it  an  impacted 
fracture  of  the  anatomical  neck;  are  the  soft  parts  implicated? 

Do  not  waste  time  in  vague  palpations  but  proceed  at  once  to  a 
systematic  examination,  under  anesthesia,  if  necessary.  Begin  by 
locating  the  apex  of  the  acromion;  if  there  is  no  depression  beneath 
it;  if  the  thumb  cannot  be  pushed  into  a  concavity  but  comes  in 
contact  as  it  should  with  the  humeral  head,  you  may  conclude  there 
is  no  dislocation.     With  the  thumb  still  in  front,  close  the  fingers  on 


214 


FRACTURES    OF   THE    EXTREMITIES 


the  posterior  aspect  of  the  head  of  the  humerus,  and  with  it  thus  held 
hrmly,  attempt  rotation  of  the  arm.     The  humeral  head  rotates  with 


Fig.    142. — Examining  the  shoulder.     Rotating  head  of  humerus. 


The  head  of  the  humerus  is  grasped  between  fingers  and  thumb  of  one  hand;  the  other 
moves  the  patient's  forearm  through  an  arc. 

In  the  case  of  dislocation  the  rotation  is  produced  with  difficulty,  if  at  all. 

In  case  of  fracture  of  the  anatomical  neck  the  joint  is  much  thickened  but  there  may 
be  slight  rotation  of  the  head.  Fracture  of  the  surgical  neck:  the  arm  is  freely  moved, 
but  the  head  does  not  rotate. 


'JRKATMEM    Ok'    I'KACTURKS    Of    TJIK    yVKM  215 

difficulty  in  dislocation;  it  does  not  rotate  at  all  if  there  is  fracture, 
and  besides,  there  is  crepitation  (Figs.  142,  143). 

A  source  of  error:  If  the  lower  fragment  overrides  much,  its  rota- 
lion  might  be  felt  and  mistaken  for  the  humeral  head.  Abduct  the 
arm;  easily  done  in  fracture,  with  increase  of  deformity  and  pain. 
Pain  is  also  produced  by  pressure  upward  at  elbow  and  by  local 
pressure  over  the  front  and  outer  side  of  humerus. 


Fig.    143. — Examining   the  shoulder.      C^^i.. paring   the  relations  of   the  coracoid  processes. 

Examine  the  axillary  space  and  all  the  other  aspects  of  the 
shoulder,  comparing  the  two  sides;  and  compare  the  other  landmarks 
of  the  arm.  Do  not  begin  any  treatment  until  the  diagnosis  is  assured. 
How  unfortunate  it  is  to  attempt  reduction  of  a  supposed  dislocation 
by  the  ordinary  method  when  it  is  complicated  by  fracture;  or  to 
treat  as  a  contusion,  a  fracture  with  displacement ! 

To  consider  briefly  the  more  common  findings  of  such  exami- 
nations: 


2l6 


FRACTURES    OF    THE   EXTREAOTIES 


I.  Fracture  of  the  surgical  neck  without  overriding  (Fig.  144)  needs 
only  the  simplest  treatment:  Brace  the  arm  on  the  inside  with  a 
''  V  "  shaped  axillary  pad,  and  with  the  forearm  flexed  at  a  right  angle; 
support  the  whole  extremity  in  a  sling  of  the  Mayor  typt.  Addi- 
tional protection  may  be  afforded  by  a  shoulder  cap  (Fig.  145). 
Begin  massage  early. 


•/^i^ 


<!«^. 


') 


Fig.  144. — Fracture  of 
surgical  neck  of  humerus. 
(Moullin.) 


Fig.  145. — Fracture  of  surgical  neck.  Axillary 
pad;  shoulder  cap;  forearm  supported  in  sling. 
(Scudder.) 


2.  Obliqiie  Fracture  of  the  Surgical  Neck  with  Much  Overriding. — • 
These  are  difficult  to  reduce;  difficult  to  maintain;  likely  to  be  mis- 
taken for  dislocation  (Fig.  146). 

Reduction. — In  making  traction,  draw  downward  and  outward  at 
first  and  then  in  the  axis  of  the  limb.  Do  not  stop  until  the  arm  is 
the  correct  length  by  measurement;  until  the  subcoracoid  projection 
has  disappeared;  until  the  acromion,  greater  tuberosity  and  the  ex- 
ternal condyle  are  in  the  same  straight  line.     Extension  must  be 


TREATMENT  OF  FRACTURES  OF  THE  ARM 


217 


maintained  while  the  dressing  is  applied  or  the  displacement  will 
certainly  recur. 

The  arm  must  be  lixed  in  abduction  and  with  the  elboiv  slightly 
forward;  only  in  this  position  will  the  lower  fragment  coapt  with 
the  upper  which,  of  course,  the  fixation  apparatus  will  not  affect. 
Either  the  patient  must  be  put  to  bed  and  extension  with  weight  and 
pulley  applied  or  else  the  rather  complicated  splints  of  the  type  used 


Fig.   146. — Fracture  of  surgical  neck  with  overriding. 

by  Heitz-Boyer  or  Dupuy  must  be  employed  to  maintain  these 
positions.  In  either  case  the  fixation  must  not  be  prolonged,  and 
massage  and  passive  movement  begun  early.  If  the  circumstances 
permit,  the  open  operation  gives  by  far  the  most  satisfactory  result. 


FRACTURE  OF  THE  SURGICAL    NECK  WITH  DISLOCATION 

This  is  a  very  serious  injury;  difficult  of  diagnosis;  of  bad  prog- 
nosis. Carrying  out  the  systematic  examination  described,  you  find 
the  head  displaced,  but  the  arm  is  not  fixed  in  abduction  as  in  the 


2l8 


FRACTURES    OF    THE    EXTREMITIES 


ordinary  dislocation;  it  drops  to  the  side.  Again,  the  head  does 
not  rotate  with  the  arm;  there  may  be  crepitation;  from  these  and 
other  confirmatory  points  the  diagnosis  is  made. 

Reduction. — Anesthesia  is  necessary.     Make  a  slow,  gentle,  Inil 


Fig.   147. — Fractxire  with  dislocation  before  reduction. 


persistent  traction  on  the  arm;  this  combined  with  manipulation  of 
the  head  of  the  humerus  in  the  axillary  space  may  succeed  in  re- 
storing the  head  to  the  glenoid  fossa,  for  more  than  likely  the 
head  is  still  attached  to  the  shaft  by  periosteum  and  muscular 
fibers.     As  the  assistant  makes  the  traction  apply  your  thumbs  to  the 


TREATMENT    OF   FRACTURES    OF    TJIK    ARM 


219 


head  in  axilla  and,  with  the  lingers  braced  by  the  shoulder,  try  to 
force  the  head  into  place  (Figs.  147,  148)- 

Once  the  dislocated  head  is  reduced,  reduce  and  treat  the  fracture 


Fig.   148. — Same  fracture  of  surgical  neck  with  dislocation  after  reduction. 

by  the  ordinary  means.  Massage  must  be  begun  especially  early. 
If  these  efforts  fail,  choice  lies  between  operation  and  expectant 
treatment. 


2  20  FRACTURES  OF  THE  EXTREMITIES 

The  expectant  treatment  may  give  a  surprisingly  good  result 
in  case  the  dislocated  part  includes  only  the  head.  With  early 
massage  and  passive  motion  a  new  joint  is  created,  the  upper  end  of 
the  shaft  adapting  itself  to  the  glenoid  cavity. 

In  case  the  dislocated  fragment  includes  the  surgical  neck  a 
persistently  stiff  shoulder  may  be  expected  and  not  only  that  but  a 
large  callus  may  seriously  interfere  with  the  brachial  plexus,  or  even 
the  axillary  vessels. 

Royster,  of  Raleigh,  N.  C.  (Journal  A.  M.  A.,  Aug.  lo,  1907),  re- 
views his  own  experience  and  the  literature  dealing  with  this  condi- 
tion, and  concludes  very  logically  that  operative  treatment  in  the 
great  majority  of  cases  is  alone  effective. 

The  preferable  incision  begins  at  the  acromion  process,  extends 
vertically  downward  as  far  as  necessary,  and  aims  to  reach  the  bone 
by  passing  between  the  pectoralis  major  and  the  deltoid.  The  head, 
thus  exposed,  is  to  be  reduced  by  manipulation,  although  oc- 
casionally a  special  hook  or  bone  forceps  may  be  necessary.  Wiring 
will  seldom  be  required  except  in  the  cases  operated  late.  The  dress- 
ing should  be  applied  so  as  to  maintain  the  arm  in  abduction. 
Royster  believes  in  immediate  operation,  regarding  such  cases  as 
emergencies,  as  much  so  as  strangulated  hernia  or  appendicitis, 
''Even  in  cases  of  doubt,  it  is  preferable  to  expose  the  parts  to  view 
rather  than  to  wait  in  the  hope  that  nature  and  time  will  clear  it  up." 
Our  own  experiences  seem  amply  to  confirm  this  view. 

FRACTURE    OF    THE    ANATOMICAL    NECK 

This  fracture  nearly  always  results  from  falls  upon  the  point  of 
the  shoulder  and  in  consequence  is  impacted.  A  fall  upon  the  elbow 
may  produce  an  impacted  fracture  of  the  upper  end  of  the  surgical 
neck  but  only  the  X-ray  could  make  the  distinction.  Great 
swelling  and  ecchymosis  are  prominent  characters  and  loss  of  func- 
tion is  complete.  Palpation  and  manipulation  reveal  nothing  but 
the  degree  of  pain. 

The  X-ray  picture  usually  shows  the  head  turned  either  forward 
or  backward  and  an  irregular  dentated  line  of  fracture.  The  treat- 
ment from  the  first  is  massage  and  passive  motion. 


TREATMENT  OF  FRACTURES  OF  THE  ARM  221 

The  massage  of  the  first  two  days  should  be  chiefly  friction;  later 
kneading  will  hasten  the  absorption  of  the  exudates.  The  passive 
motion  consists  of  gentle  flexion  and  extension  and  the  treatment 
must  not  be  such  as  to  aggravate  the  pain.  The  daily  treatment  is 
followed  by  fixation  in  a  sling. 

After  a  couple  of  weeks  the  treatment  may  be  carried  on  more 
vigorously  and  as  soon  as  the  patient  can  move  the  joint  actively  he 
must  be  directed  to  keep  at  it  many  times  each  day.  The  first 
movement  to  return  is  the  antero-posterior;  a  little  later,  rotation; 
and  last  of  all  abduction.  Often  times  in  these  cases,  in  spite  of  sys- 
tematic treatment  the  motion  is  imperfect  and  the  tenderness  per- 
sistent, especially  over  the  acromion,  the  coracoid,  and  deltoid 
tubercle. 

Fracture  of  the  greater  tuberosity  may  occur  as  the  result  of  either 
direct  or  indirect  violence,  such  as  fall  upon  the  hand  with  arm 
extended.  The  displacement  of  the  tuberosity  may  be  upward,  out- 
ward, and  backward.  Early  disability  and  swelling  are  prominent 
symptoms;  crepitus  may  be  absent.  Pain  is  produced  by  local 
pressure.  Taylor,  of  New  York,  asserts  (Annals  of  Surgery,  Jan., 
1908)  that  in  uncomplicated  cases  with  moderate  displacement 
recovery  may  be  practically  perfect  without  the  use  of  splints, 
massage,  or  special  movements,  but  on  the  whole  the  best  result  will 
be  obtained  by  immobilization  or  abduction  to  a  right  angle  with 
external  rotation. 

FRACTURE    OF    THE    UPPER    END    OF    THE    HUMERUS    IN    CHILDREN 

With  respect  to  diagnosis  and  treatment,  fractures  of  the  upper 
end  of  the  humerus  in  children  present  some  special  features. 
Practically  speaking,  there  are  but  two  types  of  injury;  fracture  of  the 
surgical  neck  and  separation  of  the  epiphysis.  The  head  and 
anatomical  neck  are  immune  by  reason  of  their  spongy  character. 

If  the  surgical  neck  is  fractured  without  displacement  of  the 
fragments  or  with  impaction,  the  pain,  loss  of  function  and  de- 
formity are  moderate.  Usually  there  is  considerable  swelHng.  The 
treatment  is  simple;  fixation  in  a  sling  for  a  week  and  thereafter 
frequent  and  gentle  passive  motion  without  massage  and  the  func- 
tions of  the  joint  are  rapidly  restored. 


2  22  FRACTURES  OF  THE  EXTREMITIES 

If  on  the  other  hand  there  is  much  displacement,  the  deformity  is 
quite  constant,  the  joint  is  thickened  in  front  and  externally  and  the 
end  of  the  lower  fragment  bulges  the  subcoracoid  area.  This  might 
be  taken  for  the  head  of  the  humerus,  but  on  palpation  the  head  is 
found  to  be  in  the  glenoid  cavity.  The  shortening  of  the  shaft  of  the 
humerus  and  the  abnormal  direction  of  its  axis  point  to  the  nature  of 
the  injury. 

These  same  signs  and  symptoms  characterize  separation  of  the 
epiphysis  but  this  lesion  is  much  the  more  serious  for  improper 
treatment  may  result  in  checking  linear  growth. 

The  treatment  is  the  same  for  the  two  conditions.  Reduction 
requires  a  general  anesthesia  and  a  definite  maneuver. 

Make  strong  traction  on  the  abducted  arm,  dircting  the  assistant 
to  press  outward  with  his  thumbs  against  the  broken  ends  which  form 
with  each  other  an  angle  pointing  toward  the  coracoid.  If  the  arm  is 
now  brought  to  the  side  the  deformity  recurs;  on  that  account  there- 
fore the  arm  is  to  be  fixed  in  abduction.  This  may  be  accomplished 
by  plaster  splints;  still  better  by  a  plaster  dressing  including  the 
thorax.  A  part  of  this  dressing  is  applied  previous  to  the  anesthesia 
and  reduction. 

The  patient  is  seated  and  a  plaster  jacket  applied,  including  the 
shoulder  but  not  the  arm. 

The  patient  is  then  anesthetized  and  the  fracture  reduced. 

The  arm  is  held  in  abduction  and  in  a  forward  position,  the 
forearm  flexed  to  a  right  angle  and  semiprone.  A  plaster  roller  is 
now  applied,  including  the  shoulder,  the  arm  and  forearm.  By  this 
means  you  fix  the  scapula  and  relax  the  abductor  group  of  muscles 
which  act  upon  the  upper  fragment;  in  this  manner  the  normal  axis 
of  the  humerus  is  maintained. 

After  two  weeks  remove  the  plaster  and  for  the  next  two  weeks 
carry  the  arm  in  a  sling,  and  function  is  soon  restored. 

FRACTURES  OF  THE  LOWER  END  OF  THE  HUMERUS 

Injuries  about  the  elbow  are  always  to  be  regarded  seriously. 
They  occur  much  more  frequently  in  children  and  are  usually  due 
to  falls  upon  the  flexed  elbow.  Scudder  insists  that  even  in  the 
apparently  trivial  cases   the  examination  should  be  made  under 


TREATMENT  OF  FRACTURES  OF  THE  ARM 


223 


Fig.   149. — Examining  the  elbow;  locating  the  three  cardinal  points — the  internal  condyle, 
the  tip  of  the  olecranon  and  the  external  condyle. 

When  the  elbow  is  flexed  at  a  right  angle  the  three  points  stand  for  the  corners  of  an 
equilateral  triangle;  when  the  elbow  is  extended  the  three  points  are  in  a  straight  line.  The 
head  of  the  radius  is  easily  felt  on  the  normal  joint  one-half  to  three-quarters  of  an  inch 
below  the  external  condyle.     Gently  rotating  the  forearm  helps  to  locate  the  capitellum. 

The  gutter  behind  the  external  condyle  is  broad  and  shallow;  on  the  ulnar  side  deeper, 
containing  the  ulnar  nerve. 


2  24  FRACTURES  OF  THE  EXTREMITIES 

anesthesia,  for  only  by  that  means,  as  a  rule,  can  the  injury  be 
exactly  diagnosed. 

The  diagnosis  itself  is  chiefly  a  matter  of  applied  anatomy.  The 
landmarks  and  the  normal  relations  must  be  clearly  in  mind.  Ob- 
serve on  the  sound  side  the  relations  of  the  internal  and  external 
condyles,  the  olecranon,  the  head  of  the  radius.  It  is  uncertain  at 
first  whether  it  is  a  contusion,-  or  dislocation,  or  fracture.  Even 
when  sure  that  the  case  is  a  fracture,  yet  it  is  to  be  determined  whether 
it  is  supracondylar,  or  condylar,  or  some  combination  of  the  two. 

Scudder  formulates  a  routine  mode  of  procedure  in  making  the 
diagnosis. 

Observe  the  character  of  the  swelling — whether  general  or 
localized. 

Observe  the  carrying  angle. 

Palpate  the  external  and  internal  condyles. 

Palpate  the  olecranon  process  and  head  of  the  ulna. 

Rotate  the  head  of  the  radius. 

Note  the  relation  of  the  three  bony  points  in  extension  and  flex- 
ion (Fig.  149)- 


Fig.    150. — Supra-condylar  fracture  of  humerus.      Note   obliquity.      (Moullin.) 

Determine  the  possible  movements  of  the  elbow-joint.  Make 
measurements.  Make  pressure  with  the  point  of  the  finger  to  locate 
a  painful  Hne  which  marks  the  fracture.  If  the  X-ray  is  used  it 
should  show  both  the  lateral  and  antero-posterior  view. 

Certain  forms  of  injury  are  found  most  frequently:  (i)  Supra- 
condylar fracture,  (2)  fracture  of  one  of  the  condyles,  (3)  multiple 
fracture  involving  the  joint. 


TREATMENT  OF  FRACTURES  OF  THE  ARM 


225 


Fig.  151- 


-Extension  fracture;  slight  backward 
displacement  of  elbow. 


(i)  Snpra-condylar  Fracture. — This  type  occurs  more  frequently 

in  children.     The  joint  is  not  usually  involved,  the  plane  of  fracture 

extending  commonly  from 
above  downward  and  for- 
ward. The  displacement  of 
the  upper  fragment,  there- 
fore, is  downward  and  for- 
ward, and  if  union  takes 
place  in  this  position  the 
flexion  of  the  elbow  is  much 
abbreviated  (Fig.  150). 

This  is  the  so-called  "ex- 
tension? fracture  (Fig.  151); 
whereas    in    the    '^ flexion" 

fracture  the  lower  fragment  is  displaced  upward  and  forward  (Fig. 

152).     It  must  be  definitely  determined  which  form  exists. 
The  extension  fracture,  by  the 

far  the  more  frequent,  simulates 

backward    dislocation    but   you 

find  the  condyles,  the  olecranon 

and   the  head  of  the  radius  in 

their  normal   relations   to   each 

other.      The   condyles    may   be 

moved     independently    of     the 

shaft  and  measuring   from    the 

acromion    to    ext.    condyle  you 

will  probably  find   some  short- 
ening and  also  the  normal  axis 

is  disturbed. 

Compared  with  the  other  joint 

there  is  no  change  in  width  which 

excludes  intercondylar  forms. 
Along  with  the  ordinary  signs 

of  fracture   the   sharp   end  of   the  Fig.  152.— Supra-condylar  fracture:  forward  dis- 
Upper    fragment    may    be    felt    in       placement  of  elbow.      ("Flexion  fracture.") 

the  flexure  of  the  elbow. 

Imperfect  reduction  of  these  fractures  leads  to  some  loss  of  move- 
rs 


226 


FRACTURES    OF    THE   EXTREMITIES 


ment  and  awkward  deformity;  and  in  many  instances  to  nerve 
complications,  the  result  of  a  large  callus.  A  ''wristdrop"  for  ex- 
ample may  gradually  develop  in  such  a  case  the  result  of  inter- 
ference with  the  musculo-spiral. 

Still  more  important,  if  the  fracture  follows  the  epiphyseal  line 
the  child's  arm  never  attains  its  normal  growth.  How  greatly 
necessary  then  that  we  recognize  not  only  the  t\pe  of  fracture 


Fig.  153. — Epiphyseal  fracture  of 
humerus;  backward  displacement  of 
elbow. 


Fig.  154. — Fracture  and  complete  dis- 
location of  the  epiphysis,  lower  end  of 
humerus. 


but  the  variations  as  well  and  that  we  know  how  to  proceed  so  as 
to  restore  form  and  function  to  the  near-normal.  And  this  is  by  no 
means  always  easy  even  when  the  X-ray  has  exposed  the  details 
of  the  bone  disturbance  (Figs.  153,  154). 

Three  displacements  are  to  be  overcome:  (a)  An  antero-posterior 
which  uncorrected  leads  to  interference  with  flexion  and  extension; 
(b)  lateral,  affecting  the  carrjdng  angle;  and  (c)  rotation,  affecting 
the  supinator  function. 

Ordinarily  vou  will  proceed  in  this  manner:  direct  the  assistant 
to  make  strong  traction  on  the  extended  forearm,  gradually  chang- 
ing the  extension  to  acute  flexion  and  while  he  does  this,  you  will 


TREATMENT   OF   FRACTURES    OF    THE   ELBOW 


227 


make  counter-traction  on  the  humerus  grasping  it  above  the  line 
of  fracture  so  as  to  pull  on  the  shaft  and  at  the  same  time  push  against 
the  olecranon  with  the  thumbs .  Grinding  and  tearing,  the  lower 
fragment  is  felt  to  move  forward.  Traction  and  counter-traction 
must  be  maintained  on  the  flexed  elbow  while  by  manipulation  the 
lateral  displacement  and  rotation  are  overcome  (Fig.  155).     Fixa- 


3- 

•^^  J 

-  — 

Fig.  155. — Supra-condyloid  fracture  of  the  humerus.  Method  of  reduction  before  ap- 
plying retentive  splint.  Counter-traction  on  upper  arm.  Traction  on  condyles  of  hu- 
merus with  right  hand;  backward  pressure  with  thumb  of  left  hand.  Also  illustrative  of 
method  of  beginning  acute  flexion.      {Scudder.) 


tion  in  forced  flexion  may  be  secured  by  encircling  bands  of  ad- 
hesive or  still  better,  we  think,  by  a  posterior  plaster  splint  made  as 
follows: 

Twelve  to  sixteen  pieces  of  crinoline  long  enough  to  reach  from  the 
deltoid  insertion  to  near  the  wrist,  and  wide  enough  to  cover  the 
arm,  are  quilted  together  and  two  oblique  notches  cut  corresponding 
to  the  bend  of  the  elbow.  This  piece  of  padding  is  now  impreg- 
nated with  liquid  plaster  and  applied  to  the  back  of  the  arm  and  fore- 
arm, and  well  molded  (Fig.  156).  The  two  notches  permit  a  ready 
adjustment  at  the  bend  of  the  elbow.     The  support  of  the  arm  is  not 


228 


FRACTURES    OF    THE   EXTREMITIES 


relaxed  until  the  plaster  has  hardened.     The  gutter  thus  formed  may 
be  strengthened  by  a  loosely  applied  roller  which  passes  from  the 

wrist  across  to  the  arm  near  the  axilla, 
around  it  and  back  to  the  wrist  again, 
and  so  on.  The  arm  is  thus  fixed  in  acute 
flexion  (Fig.  157).  Immediate  reduction, 
immediate  fixation  in  forced  flexion  is  the 
correct  formula  therefore  for  this  type  of 
injury.  But  the  case  may  be  seen  late  and 
the  swelling  be  of  such  degree  that  flexion 
is  out  of  the  question  because  of  interfer- 
ence with  the  brachial  vessels,  something 
which  must  be  watched  whatever  the  form 
of  treatment. 


Fig.  156. — Fracture  of  the 
elbow  in  the  child:  pattern  for 
plaster  splint.  Notched  so  that 
when  the  elbow  is  flexed  splint 
may  be  easily  molded. 


Fig.  157. — Fracture  of  elbow  in  the  child:  plaster 
splint  molded  to  the  flexed  elbow. 


A  boy  of  twelve  years  was  brought  in  from  the  country  with  an 
injury  received  the  day  before  by  being  thrown  from  a  horse.  A 
diagnosis  of  fracture  about  the  elbow  had  been  made,  and  with  it 


TREATMENT   OF   FRACTURES    OF   THE   ELBOW  229 

the  effort  to  fix  the  arm  in  forced  flexion.  The  whole  member  was 
greatly  swollen,  edematous  about  the  elbow  with  blebs  in  process  of 
formation.  The  X-ray  confirmed  the  diagnosis,  showing  epiphyseal 
separation  with  fracture  and  separation  of  the  internal  condyle. 
The  dressing  was  removed,  the  arm  fixed  in  extension;  daily  light 
massage  was  instituted  to  remove  the  tumefaction,  and  after 
four  days  an  effort  was  made  to  .reduce  the  fragments  and  put  the 
arm  in  forced  flexion;  but  this  only  resulted  in  complete  obliteration 
of  the  radial  pulse.  The  arm  was  left  in  semiflexion  and  pronation, 
and  very  light  massage  was  again  instituted  for  a  few  days;  gradually 
the  swelling  subsided,  and  after  the  end  of  a  week  more  another 
effort  was  made  to  reduce  under  general  anesthesia,  with  better 
results.  After  a  week  of  fixation  in  the  corrected  position  the  mas- 
sage was  begun  again  and  continued  for  some  weeks.  Eventually 
the  restoration  of  function  was  almost  complete. 

Massage  in  the  case  of  these  elbow  injuries  in  children  is  likely  to 
do  more  harm  than  good  and  should  have  for  its  only  object  the  ab- 
sorption of  the  exudates.  Too  freely  used,  it  overstimulates  the 
new  bone  formation  and  produces  excessive  callus  which  in  this  case 
we  wish  particularly  to  avoid  lest  the  olecranon  and  coronoid  fossae 
be  obliterated.  Nor  need  we  concern  ourselves  too  much  with 
passive  motion.  If  the  joint  surfaces  are  free  we  may  expect  the 
child  gradually  and  unconsciously  to  increase  the  amplitude  of  the 
movements  and  in  one  to  five  months  a  practical  restoration  of 
function  is  the  rule.  Finally  there  is  to  be  mentioned  the  occasional 
case  which  comes  in  two  or  three  weeks  after  the  accident  with  the 
fragments  unreduced  and  at  this  time  irreducible.  Such  cases  are 
by  no  means  hopeless  for  the  bone  may  be  exposed,  the  periosteum 
turned  back,  the  fragments  pried  apart,  the  callus  chipped  away  and 
the  raw  bone  surfaces  adapted;  the  limb  fixed  in  flexion  and  there- 
after treated  as  a  primary  fracture. 

FRACTURE  OF  THE  EXTERNAL  CONDYLE 

This  accident  is  not  infrequent  in  children,  due  to  fall  upon  the 
outstretched  hand  the  force  being  transmitted  through  the  radius 
to  the  condyle.     In  the  adult  a  direct  force  is  required. 

The  diagnosis  is  easy  before  much  swelling  occurs;  after  that  it 


230 


FRACTURES  OF  THE  EXTREMITIES 


can  be  made  with  certainty  only  by  the  X-ray.  The  ecchymosis, 
the  pain  on  pressure,  the  Umited  flexion,  and  painful  supination, 
point  to  the  nature  of  the  injury. 

The  fragment  may  be  displaced  upward  or  downward  and  may 
be  rotated  as  well.     (Fig.  158.) 


I 


Fig.   158. — Fracture  of  the  external 
condyle  in  the  child. 


Fig.    159. — Fracture  of   internal 
condyle.      (Moullin.) 


Reduction,  sometimes  difficult,  is  accomplished  by  manipula- 
tion and  the  arm  is  to  be  put  in  plaster  in  either  extension  or  flexion 
depending  upon  which  holds  the  fragment  in  place.  The  dressing 
should  be  removed  about  the  end  of  the  second  week  and  the  child 
encouraged  to  use  his  arm.  In  one  or  two  months  the  junction  will 
be  nearly  restored.  Massage  as  mentioned  before  is  not  desirable 
in  fractures  about  the  elbow. 

FR-\CTURE    OF    THE   INTERNAL   CONDYLE 

This  fracture  is  not  nearly  so  frequent  in  children  as  the  supra- 
condylar form  or  even  fracture  of  the  external  condyle  because  the 


TREATMENT    OF   FRACTURES    OF   THE   ELBOW  23 1 

force  of  a  fall  on  the  hand  is  much  more  likely  to  be  transmitted 
through  the  radius  which  abuts  on  the  external  condyle  (Fig.  159). 

In  the  adult,  however,  the  internal  condylar  fracture  is  the 
more  frequent  and  is  due  to  direct  violence. 

It  derives  its  importance  from  the  loss  of  joint  function,  the 
muscular  disability,  or  the  nerve  complications  which  may  ensue. 


Fig.   160. — Fracture  of  the  internal  condyle  with  backward  dislocation  of  elbow. 

The  movements  of  the  olecranon  process  are  likely  to  be  impaired, 
the  ulnar  nerve  likely  to  be  compressed  by  the  callus;  the  flexor  group 
of  muscles  attached  thereto  impaired  by  the  shift  in  their  point  of 
attachment. 


;^:!S!| 


232  FRACTURES    OF   THE    EXTREMITIES 

The  symptoms  and  signs  of  fracture  of  the  external  condyle 
apply  with  equal  force  here.  Practically  the  same  mechanical 
principles  operate  to  produce  displacement,  rotation  and  tilting  of 
the  fragments. 

The  diagnosis  is  to  be  made  from  these  symptoms  and  signs, 
coupled  with  the  physical  examination. 

It  may  be  readily  mistaken  for  a  backward  dislocation,  for  if  the 
head  of  the  radius  is  out  of  place  the  fragment  may  move  backward 

carrying  the  ulna  with  it.  In  the 
case  of  children  there  may  be  actual 
dislocation  along  with  the  fracture 
(Fig.  160). 
The  X-ray  will  confirm  these  find- 
i  ings.     The  treatment,  if  no  displace- 

V\  ment  exists,  is  simple;  firm  bandag- 

ing and  the  forearm  fixed  at  a  right 
angle  in  a  sling. 
\  If  the  displacement  is  marked  the 

\      position    of    fixation    will    be    that 
5^    which  best  maintains  the  reduction. 
\         H         y      '       ^1    Usually    this    will  be   flexion   since 

"/     thereby    the    attached    muscles   are 
relaxed. 

After   a   few   days  gentle  passive 
Fig.  161.— Intercondylar  fracture       motion  should  be  practised  as  the 

of  humerus.      (Moullin.) 

best  means  of  moldmg  the  formmg 
callus  and  keeping  the  fossae  clear.  In  the  course  of  a  few  months 
the  joints  functions  will  be  normal.  If  the  fracture  is  complicated 
by  dislocation,  this  may  be  easily  reduced  by  traction  in  extension 
and  subsequently  fixing  the  elbow  in  forced  flexion. 

If  flexion  is  much  limited  it  is  certain  that  the  fragment  is  locked 
in  the  joint  and  an  open  operation  should  be  practised  without  delay. 

(3)  The  intercondyJar  and  midtiple  fractures  involving  the  joint, 
as  they  do,  require  a  very  guarded  prognosis  (Fig.  161).  By  referring 
to  the  landmarks,  the  displacements  are  to  be  figured  out  and  the 
fragments  are  to  be  manipulated  until  all  the  movements  of  the 
joint  are  restored. 


TREATMENT    OF   FRACTURES    OF    THE    ELBOW  233 

The  forearm  is  then  to  be  acutely  flexed  and  fixed  either  by  the 
adhesive  strips  or  plaster  splints  as  before  described.  If  the  dis- 
placements cannot  be  held  by  this  means  the  fracture  must  be 
treated  by  extension  for  a  few  days  and  then  put  up  in  acute  flexion. 
Massage  and  passive  motion  must  be  very  early  begun  in  these  cases 
and  persisted  in  for  a  long  time. 

FRACTURE  OF  THE  OLECRANON 

Following  fractures  of  the  lower  end  of  the  humerus,  fractures  of 
the  olecranon  should  be  next  considered  for  the  same  anatomical 
features  are  to  be  recalled  in  diagnosis.  The  diagnosis  of  this 
fracture  has  no  particular  feature  but  is  to  be  made  by  inspection, 
palpation  of  the  landmarks  mentioned  and  by  manipulation. 
This  break  is  usually  due  to  direct  violence,  sometimes  to  muscular 
action.  The  amount  of  separation  of  the  fragments  depends  upon 
the  amount  of  the  tear  in  the  fibrous  attachments  of  the  triceps,  and 
is,  of  course,  most  marked  in  flexion,  and  is  increased  by  swelling  of 
the  joint.     A  complete  fracture  opens  into  the  joint. 

As  to  the  treatment  it  is  obvious  that  no  one  method  is  equally 
applicable  to  all  cases.  There  can  be  no  doubt  that  the  method  of 
choice,  where  it  is  possible,  is  suturing. 

If  this  is  not  advisable,  or  not  permitted,  the  next  best  procedure 
is  the  treatment  by  massage  begun  immediately — and  this  whether 
there  is  much  or  little  separation.     No  immobilization,  only  massage. 

If  asepsis  can  be  assured  or  if  the  fracture  is  compound,  suture  is 
indicated.  The  operation  is  not  difficult.  The  bone  is  exposed  by  a 
transverse  incision,  or  if  there  is  a  wound  it  may  be  enlarged.  Cleanse 
the  wound  of  all  exudates  and  trim  away  the  ragged  tissues;  next 
expose  the  fracture,  separate  the  fragments  and  expose  and  cleanse 
the  joint. 

There  are  several  methods  of  suture.  If  the  fracture  is  transverse, 
the  periosteum  on  each  side  is  laid  back  and  two  holes  drilled  in  each 
fragment  for  the  passage  of  two  silver  wires.  When  a  wire  is  passed 
its  ends  are  twisted  and  the  coaptation  perfected.  The  drill  holes 
should  not  involve  the  cartilage.  The  wires  are  cut  short  and  ham- 
mered dowTi  smooth,  and  the  periosteum  and  fibrous  sheath  sutured, 
and  the  skin  wound  repaired  without  drainage.     The  arm  is  im- 


234 


FRACTURES  OF  THE  EXTREMITIES 


mobilized  in  flexion  for  eigl>t  or  ten  days  and  then  massage  is  begun. 
The  main  object  of  which  is  to  prevent  permanent  contraction  of 
the  triceps.  By  this  means  the  fragments  are  kept  as  nearly  as 
possible  in  contact  but  even  in  the  most  favorable  cases  the  union  is 
merely  fibrous. 

If  the  fragments  are  split,  they  may  be  each  perforated  from 
without  inward  and  a  suture  passed  and  tied  on  the  outer  side.     By 


Fig.   102. — Suture  of  the  olecranon.     The  suture  in  the  form  of  a  transverse  loop 
perforates  the  lower  and  two  upper  fragments.      (Schwartz.) 

this  means  the  fragments  are  all  drawn  into  coaptation.  If  the 
upper  fragment  is  small  the  upper  transverse  perforation  may  involve 
only  the  tendon. 

A  carpenter  fell  from  his  ladder,  striking  the  point  of  his  elbow 
upon  the  sharp  edge  of  a  timber.  The  joint  was  laid  wide  open,  the 
olecranon  broken  across  transversely  and  split  as  well.  At  the 
Deaconess  Hospital  the  joint  was  cleansed  thoroughly  with  normal 
salt  solution,  the  mangled  tissue  trimmed  away.  The  fragments 
were  exposed  by  free  use  of  the  rugine.  Two  transverse  holes  were 
drilled,  the  upper  one  including  both  fragments  (Fig.  162).     Chromi- 


FRACTURE  OF  THE  OLECRANON 


235 


cized  catgut  was  used  to  draw  the  fragments  together.  The  single 
suture  was  quite  sufficient  to  secure  coaptation.  A  small  drainage- 
tube  was  left  in  the  joint  cavity.  The  periosteum  was  repaired 
(Fig.  163),  and  the  soft  parts  closed  with  additional  drainage. 
After  the  third  day,  the  tube  in  the  joint  cavity  was  removed 
permanently.  •   There  was 'a  little  suppuration  in  the  soft  parts  and 


Fig.   163. — Suture  of  the  olecranon.     Repairing  the  periosteum  by  a  continuous 

catgut  suture.     (Schwartz.) 


the  superficial  drainage  was  retained  for  a  week.  At  the  end  of  ten 
days  the  soft  parts  being  healed,  the  position  of  the  elbow  was 
changed  from  extension  to  flexion  and  daily  passive  motion  and  mas- 
sage was  begun.     The  result  was  perfect  use  of  the  joint. 

J.  B.  Murphy  has  devised  and  recommends  a  method  of  subcu- 
taneous suture  (Jour.  Am.  Med.  Assn.,  Jan.  27,  1906).  Begin  by 
making  a  small  incision  over  the  external  border  of  the  olecranon 


236  FRACTURES    OF   THE   EXTREMITIES 

below  the  line  of  fracture.  Through  this  small  opening  {iH  inches) 
drill  the  olecranon  transversely,  and  over  the  point  of  emergence  of 
the  drill  on  the  inner  border  of  the  olecranon  incise  the  skin  again. 
An  aluminum-bronze  wire  is  passed  through  the  drill-hole  from 
without  inward  and  the  inner  end  is  pushed  up  under  the  skin  along 
the  internal  border  of  the  olecranon  to  the  level  of  the  apex  of  the 
bone.  At  this  level  another  incision  is  made,  the  end  of  the  wire 
recovered  and  pushed  through  the  tendon  of  the  triceps  from  within 
outward.  A  fourth  small  incision  is  made  over  the  end  of  the  wire  to 
the  outside,  and  the  end  of  the  wire  again  directed  under  the  skin  to 
the  starting  point  and  there  tied  tightly,  in  that  manner  approxi- 
mating the  fragments.     Close  the  skin  wounds. 

FRACTURE  OF  THE  HEAD  OF  THE  RADIUS 

Another  fracture  not  infrequent  should  be  considered  in  con- 
nection with  injuries  about  the  elbow  and  that  is  fracture  of  the  head 
of  the  radius.  It  is  the  result  of  direct  violence,  or  indirectly  by  falls 
upon  the  hand.  The  fracture  is  usually  vertical,  much  or  little  of 
the  articular  surface  being  broken  off.  It  derives  its  importance  from 
the  fact  that  it  may  interfere  with  all  the  functions  of  the  elbow-joint 
— 'flexion,  extension;  rotation,  supination.  The  diagnosis  will 
usually  require  the  X-ray;  nevertheless  the  absence  of  change  in 
the  landmarks  along  with  swelling  and  tenderness  and  especially  the 
pain  on  supination  and  pronation  should  point  to  the  character  of  the 
break.  Sometimes  crepitation  may  be  felt  by  pressing  the  thumb 
over  the  radio-ulnar  joint  while  rotating  the  forearm. 

The  treatment  required  will  most  frequently  be  excision  of  the 
fragment  followed  by  two  weeks'  fixation  in  semipronation,  and  after 
this  passive  motion.     The  results  are  good. 

The  neck  of  the  radius  may  be  broken  in  much  the  same  manner. 
The  lower  fragment  is  drawn  upward  by  the  biceps.  Flexion  of  the 
forearm  combined  with  traction  and  manipulation  will  effect  a 
reduction  and  the  forearm  which  is  flexed  for  two  weeks  in  flexion 
and  semisupination.  The  point  is  to  keep  the  biceps  from  acting 
on  the  lower  fragment  (Fig.  164). 


FRACTURES  OF  THE  SHAFT  OF  ULNA  AND  RADIUS 


237 


FRACTURES  OF  THE  FOREARM 


Fractures  of  the  shaft  of  the  ulna  and  radius  are  of  the  greatest 
importance  because  of  the  possible  evil  consequences,  immediate 
or  remote.  The  chances  of  gangrene,  of  deformity,  of  anchylosis 
or  paralysis  are  never  slight.     This  prospect  of  a  crippled  or  useless 


Fig.   164. — Fracture  through  neck  of  radius.     Head  displaced,  requiring  excision. 


arm  or  hand  must  put  us  on  our  guard.  There  are  several  anatomical 
points  to  be  kept  in  mind  as  regulating  both  the  diagnosis  and  treat- 
ment. The  relative  position  of  the  two  bones  in  the  stages  of  rota- 
tion; the  attachments  of  the  biceps,  the  supinator,  and  the  pronators 
and  their  pull  upon  the  fragments;  the  interosseous  membrane;  the 
variations  in  relative  size  and  strength  of  the  two  bones  at  different 
levels;  these  are  all  factors  to  be  taken  into  account  in  the  study  of 


238 


FRACTURES    OF   THE   EXTREMITIES 


the  mechanism  of  these  fractures.  They  are  produced  by  direct  or 
indirect  violence;  in  the  latter  case,  most  frequently  by  falls  upon 
the  hands,  but  it  is  to  be  noted  that  such  accidents  are  more  likely  to 
produce,  in  the  adult,  a  Colles's  fracture;  in  the  child,  a  supra-con- 
dylar  fracture  of  the  humerus.  The  middle  third  of  these  bones  is 
most  likely  to  suffer,  the  radius  breaking  at  a  higher  level  than  the 

ulna.  The  radius  loses  strength  up- 
ward; the  ulna,  downward  (Figs.  165, 
166). 

Deformity  and  displacement  may 
exist  in  any  degree.  Thus  one  bone 
may  be  broken  completely,  a  green-stick 
fracture  occur  in  the  other.  There  may 
be  only  a  slight  angulation,  or  some 
lateral  displacement  or  extreme  overrid- 
ing. Naturally,  fracture  of  both  bones 
presents  the  worst  prognosis.  The  dis- 
placements of  the  radius  are  always  the 
more  difficult  to  manage  because  of  the 
tendency  of  the  two  fragments  to  rotate 
in  different  directions. 

Thus  the  upper  fragment  is  rotated 
outward  by  the  biceps;  and  the  lower, 
inward  by  the  pull  of  the  two  pronators. 
The  diagnosis  is  not  difficult.  The  patient  presents  himself  sup- 
porting the  injured  arm  which  tends  to  turn  inward  below,  and  out- 
ward above.  Pain,  deformity,  mobility  and  perhaps  crepitation  are 
present.  Lateral  pressure  wherever  applied  excites  pain  at  the  site 
of  fracture.  Comparative  measurements  in  the  case  only  one  bone  is 
fractured  will  show  but  little  shortening;  or,  if  there  is  much  shorten- 
ing it  is  certain  the  other  bone  is  dislocated  at  the  elbow.  For  ex- 
ample, isolated  fracture  of  the  ulna  with  overriding  is  accompanied 
by  forward  dislocation  of  the  head  of  the  radius. 

Treatment. — Whether  one  shaft  is  broken  or  both,  the  principles 
of  treatment  are  the  same.  Principally,  it  is  obliteration  of  the 
interosseous  space  which  must  be  guarded  against,  lest  pronation 
and  supination  be  lost.     The  contrary  rotation  of  the  two  fragments 


Fig.  165. — Fracture  of  both  bones 
of  forearm  due  to  crushing  injury; 
in  this  case  the  fracture  of  the  radius 
is  at  the  lower  level. 


TREATMENT    OF   FRACTURES    OF    THE   FOREARM 


239 


of  the  radius  determines  the  position  in  which  the  forearm  must  be 
fixed. 

Complete  supination  fulfills  these  two  main  indications;  it  separates 
the  shafts  most  widely;  it  permits  the  lower  fragment  of  the  radius 


Fig.   166. — Fracture  of  the  shaft  of  ulna  with  separation  of  the  epiphysis;  fracture 
of  the  shaft  of  the  radius,  too  high  for  a  CoUes'  fracture. 


to  fall  in  line  with  the  upper  which  is  fixed  by  the  pull  of  the  biceps. 
Reduction  presents  no  special  difficulties,  theoretically,  but  a  perfect 
coaptation  is  seldom  secured.  Nevertheless  an  excellent  functional 
result  is  the  rule.  Under  anesthesia,  with  the  forearm  supinated  and 
flexed,  strong  traction  and  counter-traction  aided  by  manipulation 


240 


FRACTURES  OF  THE  EXTREMITIES 


of  the  fragments,  will  bring  them  into  place.     Maintaining  the  trac- 
tion and  supination,  the  dressing  is  applied.     The  simple  anterior- 


FiG.   167. — Anterior  and  posterior  splint  for  forearm.      {Heath.) 

posterior  splint  (Fig.  167)  is  of  little  use,  except  in  isolated  fracture  of 
the  ulna,  because  it  does  not  maintain  supination.  Whatever  dress- 
ing is  used,  it  must  have  one  negative  character;  it  must  not  compress 


Fig.   168. — Method  of  supporting  arm  while  applying  plaster  bandage. 


the  forearm  laterally  lest  the  bones  be  forced  together  and  the  inter- 
osseous membrane  be  obliterated.  A  plaster  bandage  may  be  used 
including  the  supinated  forearm,  the  wrist  and  elbow  (Figs.  168, 169). 


TREATMENT    OF    FRACTURES    OF    THE   FOREARM 


241 


A  molded  plaster  splint  is  still  better,  fashioned  in  this  manner: 
Twelve  to  fifteen  layers  of  crinoline  are  cut  in  the  form  of  an  irregu- 
lar quadrilateral  long  enough  to  reach  from  the  axilla  to  the  palm 
and  wide  enough  to  encircle  the  arm  are  loosely  quilted  together  to 
form  a  splint.  It  is  notched  where  it  is  to  support  the  elbow  and  a 
hole  cut  near  one  border  for  the  thumb.     The  splint  is  soaked  in 


Fig.    169. — Fracture  of  forearm.      Plaster-of-Paris  splint 
applied.     Elbow  at  right  angle.      (Scudder.) 

liquid  plaster  and  then  molded  to  the  posterior  surface  of  the  arm 
and  finally  fixed  with  a  loosely  applied  roller.  This  is  the  best 
dressing  for  children.  In  the  case  of  adults  it  may  be  necessary  in 
some  instances  to  apply  extension  to  prevent  overlapping. 

In  any  event  extreme  care  must  be  taken  to  prevent  compression 
of  nerves  and  arteries  lest  an  ischemic  paralysis  occur. 


FRACTURES  OF  THE  LOWER  END  OF  THE  RADIUS 

Certain  landmarks  about  the  wrist  are  useful  in  diagnosis  of  in- 
juries in  this  region. 
16 


242 


TRACTURES    OF    THE    EXTREMITIES 


The  styloid  processes  are  easily  palpated,  the  radial  styloid  lying 
nearer  the  joint  line.  The  radio-carpal  joint  line  is  indicated  on  the 
anterior  surface  by  the  higher  of  three  transverse  creases.  In 
supination,  the  styloid  of  the  ulna  lies  in  the  plane  of  the  posterior 
surface  while  the  radial  lies  nearer  the  anterior  plane.  The  radial 
styloid  can  be  best  felt  in  the  depression  at  the  base  of  the  thumb, 
between  the  long  and  short  extensior  tendons.     The  two  wrists 


Fig.  170. — Typical  Colles'  fracture; 
impacted  fracture  of  lower  end  of  radius 
and  fracture  of  styloid  process  of  ulna. 


Fig.  171. — Colles  fracture;  marked  impac- 
tion, lateral  displacement  producing  widening 
of  the  wrist. 


should  be  compared  point  for  point.  In  the  skiagraph  the  epiphyseal 
lines  are  distinct  up  to  twenty  years  of  age. 

A  variety  of  fractures  may  occur  in  the  lower  end  of  the  radius 
but  by  far  the  most  frequent  and  most  important  is  that  produced 
by  falls  upon  the  outstretched  palm.  The  direction  of  the  force  is 
such  that  the  hand  is  shoved  against  the  end  of  the  radius,  carrying 
it  backward  at  the  same  time.  As  a  result  the  lower  end  of  the 
radius  is  driven  into  the  shaft,  shoved  backward  and  rotated  toward 
the  ulna  (Figs.  170,  171). 

Colles'  fracture  is  one  of  the  most  easily  recognized;  producing 


COLLES     FRACTURE 


243 


the  characteristic  hump— the  silver  fork  deformity  (Fig.  172).  But 
it  is  by  no  means  seldom  that  fracture  occurs  without  deformity. 
In  addition  to  the  injury  to  the  bone,  the  inter-articular  fibrocartilage 
may  be  torn  loose  from  both  its  attachments,  the  radio-ulnar  liga- 


FiG.   172. — Colles'  fracture.     Silver  fork  deformity.      (Moullin.) 

ments  are  strained  or  ruptured,  and  the  head  of  the  ulna  carried 
forward.  Sometimes  the  tendon  sheaths  are  lacerated  and  blood 
extravasated  into  the  synovial  sac. 

Diagnosis. — -Determine  the  position  of  the  styloid  processes  of  the 


Fig.  173. — Reduction  of  Colles'  fracture.  Note  grasp  upon  forearm  and  the  lower 
fragment  of  the  radius,  traction  and  counter-traction  being  made;  breaking  up  the 
impaction.     (Scudder.) 


radius  and  ulna.  If  there  is  a  fracture  the  styloid  of  the  radius  is 
pushed  up  to  a  level  with  that  of  the  ulna,  the  wrist  is  broadened. 
The  transverse  lines  on  the  flexor  surface  of  the  wrist  are  deepened 
and  the  axis  of  the  limb  bent  toward  the  radial  side.     The  pain  is 


244 


FRACTURES  OF  THE  EXTREMITIES 


pronounced,  mobility  and  crepitus  are  absent.  Pain  is  elicited  by 
point  pressure  across  the  radius,  an  inch  above  the  wrist. 

The  X-ray  is  very  useful  in  diagnosis  of  these  fractures. 

Reduction  is  often  difficult,  but  it  is  the  chief  thing  and  must  be 
complete,  otherwise  the  result  will  be  a  disappointment.  Anesthesia 
is  usually  necessary.  Clasp  the  patient's  hand  in  your  own,  palm 
to  palm,  and  with  the  other  hand  grasp  the  wrist  at  the  site  of 


Fig.  174. — Plaster  splint  molded  to  maintain  flexion  and  adduction,  as  shown  in  the  two 

views. 


fracture.  While  the  assistant  makes  counter-traction  you  make 
forcible  traction  on  the  hand,  at  the  same  time  inclining  it  to  the 
ulnar  side  and  making  pressure  upon  the  fragments.  This  combined 
traction,  pressure  and  ulnar  flexion  may  require  force,  but  it  will 
quickly  reduce  the  fracture  (Fig.  173). 

Another  method  consists  in  having  the  assistant  support  the  arm 
extended  and  supinated  while  you  grasp  the  hand  in  such  manner 
that  your  two  thumbs  may  make  strong  pressure  on  the  dorsum  of 
the  wrist. 

The  fragments  grate  as  the  deformity  recedes. 

Flexion  and  adduction  are  the  capital  points  in  this  procedure  and 
these  positions  must  be  maintained  (Fig.  174).  The  best  dressing  is 
indicated  in  Fig.  175;  or  a  roller  plaster  dressing  may  be  applied, 
reviewing  the  position  of  the  hand  before  the  plaster  hardens  (Fig. 


COLLES'   FRACTURE 


245 


176).  In  some  cases  when  the  displacement  has  been  sHght  simple 
anterior  and  posterior  splints  padded  to  suit  the  shape  of  the  hand, 
may  be  employed. 

There  is  very  little  tendency  to  recurrence  of  the  deformity  if  it  is 
properly  reduced,  and  the  fixation  is  a  secondary  matter.  If  there 
was  no  deformity,  or  a  very  slight  one  easily  reduced,  it  may  be 

treated  altogether  by  massage. 
Otherwise  a  week's  fixation  in  one  of 
the  dressings  just  described  is  advisa- 
ble, to  be  followed  by  active  massage. 


Fig.   175. — Pattern  for  plaster 
splint  for  CoUes'  fracture. 


Fig.   176. — Fracture  of  metacarpus. 


Andrews,  of  Mankato,  Minn.,  emphasizes  the  necessity,  in  a 
reduction  of  this  fracture,  of  a  general  anesthesia  and  a  knowledge  of 
the  anatomy  of  the  parts,  which  latter  will  be  of  more  value  to  the 
tyro  than  any  confusing  description  of  the  manner  of  taking  hold  of 
the  parts.  He  remarks  further  that  the  head  of  the  ulna  must  be 
brought  back  to  rest  in  the  sigmoid  of  the  radius. 

Thinking  the  fracture  set  when  merely  the  lower  fragment  of  the 
radius  is  in  position  is  a  mistake  that  has  brought  sorrow  to  many 
a  surgeon  after  union  has  taken  place. 

The  most  frequent  permanent  deformity  is  the  slumping  forward  of 
the  ulna  and  the  widening  of  the  wrist.  Andrews  does  not  believe 
that  early  passive  motion  does  a  great  deal  of  good  and  may  do  harm 


246  FRACTURES    OF   THE    EXTREMITIES 

by  keeping  the  joint  irritated  by  increasing  the  amount  of  callus  and 
by  causing  useless  suffering.  Early  massage,  if  gentle,  is  not  only 
permissible,  but  to  be  recommended  (Amer.  Jour.  Surg.,  July,  1909). 

FRACTURES  OF  CARPUS  AND  HAND 

Fractures  of  the  bones  of  the  carpus  are  not  infrequent,  and  may 
occur  with  fractures  at  the  lower  end  of  the  radius.  The  scaphoid 
is  the  most  frequently  involved,  either  alone  or  with  one  of  the  other 
bones.  The  injury  results  most  frequently  from  a  fall  upon  the  hand 
when  it  is  extended  and  abducted. 

Fracture  will  be  suspected  from  the  pain  and  loss  of  function,  and 
on  examination  the  styloid  process  of  the  radius  is  found  too  close  to 
the  base  of  the  first  metacarpal,  and  the  "tabatiere  anatomique" — • 
the  depression  at  the  base  of  the  thumb  between  the  long  and  short 
extensqjs  of  the  thumb — is  occupied  by  a  hard  body  and  pressure 
there  is  exceedingly  painful.  This  sign  alone  is  diagnostic  of 
fracture  of  the  scaphoid.  Point  pressure  in  case  of  fracture  elicits 
much  pain.  Often  the  thenar  eminence  is  ecchymosed.  The  exact 
character  of  the  lesion  can  only  be  determined  by  the  X-ray.  Re- 
duction may  be  accomplished  by  putting  the  hand  in  the  ulnar 
flexion  and  making  pressure  on  the  fragments  through  the  palm. 
Excision  may  be  necessary. 

Another  type  of  injury  consists  of  fracture  of  the  scaphoid  with 
dislocation  of  the  semilunar.  This  is  due  to  a  fall  upon  the  hand  and 
is  accompanied  by  pain,  swelling  and  loss  of  flexion  of  the  wrist,  loss 
of  extension  of  the  fingers.  The  displaced  semilunar  may  be  felt 
in  the  palmar  surface  and  the  fossa  at  the  base  of  the  thumb  is 
filled  up.     On  the  back  of  the  wrist  the  os  magnum  may  be  felt. 

These  cases  untreated  are  likely  to  terminate  in  anchylosis  of  the 
wrist. 

The  treatment  consists  in  hyperextension  of  the  wrist  (under 
anesthesia)  with  the  purpose  of  faciHtating  the  pressure  into  its 
place  of  the  semilunar.     Subsequently  the  hand  is  flexed  in  flexion. 

In  neglected  cases  it  may  be  necessary  to  resect  the  semilunar  in 
order  to  restore  function. 

Fracture  of  the  metacarpals  is  to  be  diagnosed  by  swelling,  tender- 


FKACTUKKS    OF   THE   FINGEKS 


247 


Fig.  177. — Showing  "sway-backed"  appear- 
ance after  fracture  of  the  first  phalanx  of  mid- 
dle finger.      {Marsee.) 


ness,  loss  of  function,  and 
sometimes  by  crepitation  and 
mobility  (Fig.  176). 

The  nature  and  degree  of 
the  displacement  is  variable 
and  is  often  quite  indetermina- 
ble without  lateral  and  antero- 
posterior X-ray  views.  The 
deformity  is  to  be  overcome  by 
traction  on  the  corresponding 
linger  confined  with  pressure. 
The  palm  is  padded  with  cot- 
ton and  firmly  bandaged. 

About  three  wxeks  is  required  for  repair. 

Fracture  of  the  metacarpal 
of  the  thumb  has  some  special 
characters  and  is  designated  as 
Bennett's  fracture  of  stave  of 
the  thumb. 

It  is  probably  the  most  com- 
mon and  is  the  most  important 
of  the  metacarpal  fractures, 
difhcult  to  reduce  and  hold. 

After  reduction  a  plaster 
spica  may  be  applied  with  the 
thumb  abducted  and  subse- 
quently a  window  may  l)e  cut  in  the  plaster  over  the  base  of  the 
thumb  and  padding  applied  to  press  the  fragments  into  place.  In- 
stead of  plaster  three  well- 
padded  pencil  splints  may  be 
used. 

Fracture  of  the  fingers  is 
sometimes  compound,  requir- 
ing a  careful  antisepsis.  There 
is  usually  a  tendency  to  dis- 
placement, so  that  after  reduc- 

.  .  Fig.  179. — Mode  of  adjusting  splint  for  simple 

tlOn       Splmtmg       is       necessary.  fracture  of  the  finger.      {Marsee.) 


Fig. 


178. — Splint   with  attachment  for  correc- 
tion of  lateral  deformity.      (Marsee.) 


248 


FRACTURES    OF    THE    EXTREMITIES 


Fig.  i8o. — Splint  wrapped  with  gauze  ad- 
justed for  fracture  of  first  phalanx,  index 
finger.      {Mar  see.) 


A  well-padded  palmar  splint  is  often  all  that  is  necessary,  retain- 
ing it  by  bandages  or  adhesive 
strips. 

In  many  cases,  however,  the 
matter  is  not  so  simple  and  it 
cannot  be  denied  that  the 
splints  ordinarily  used  are 
often  very  unsatisfactory,  for 
they  are  not  seldom  so  fash- 
ioned as  to  be  inadequate  to 
maintain  extension,  to  immo- 
bilize perfectly,  or  to  correct 
deformity. 
The  first  or  proximal  phalanx  most  frequently  suffers  and  the 

fragments   are  likely  to  bulge 

toward    the   palm,   giving   the 

finger    a    ''sway-backed"    ap- 
pearance (Fig.  177).    As  Marsee 

has  pointed  out,  this  deformity 

will  not  yield  to  the  ordinary 

splint,  not  indeed  to  any  splint 

which  is  straight  or  but  slightly 

curved. 

The  appliance  recommended 

for  this  condition  and  which  may  be  useful  in  any  fracture  of  the 

digits  consists  of  a  strip  of  tin,  zinc,  copper,  or  galvanized  iron, 

14  inches  long  and  2}i  inches 
wide.  This  is  to  be  folded 
upon  itself  lengthwise  and 
hammered  flat  so  as  to  make 
a  three-ply  strip  three-fourths 
of  an  inch  in  width.  Of  what- 
ever material  made,  it  should 
be  just  flexible  enough  to  be 
Fig.  182  —Splint  applied.    Palmar  aspect,    j^ej^^-  readily    by    the    unaidcd 

{Marsee.)  ^^  ^       r      ^ 

fingers,     upon  one  end  of  the 
strip,  a  piece  of  thin  leather  or  canvas  4  or  5  inches  long  and  3 


Fig.  181. 


-Finger  splint  applied, 
aspect.       (Marsee.) 


Dorsal 


FRACTURES    OF    THE    FINGERS 


249 


Fig.  183. — Lateral  angular  deformity 
of  middle  finger.  Unsightly  stump  of 
index.      {Marsee.) 


inches  wide  is  to  be  riveted  (Fig.  178)  in  order  to  give  the  strip 
stability  when  bandaged  to  the  forearm.  The  strip  is  then  shaped 
to  suit  the  curved  outline,  in 
which  position  the  fingers  should 
be  immobilized  (Figs.  179,  180). 
The  splint  is  to  be  adjusted 
snugly  to  the  forearm,  so  that  its 
end  projects  slightly  beyond  the 
tip  of  the  finger,  and  fastened  by 
strips  of  adhesive  plaster,  by  a 
roller  bandage,  or  by  a  light 
plaster-of-Paris  casing.  The  fin- 
ger, carefully  wrapped  in  several 
thicknesses  of  gauze,  is  then  ad- 
justed with  painstaking  care  to 
the  splint  in  such  a  manner  that 
the  deformity,  if  any,  is  thoroughly 
overcome,  and  longitudinal  and 
circular  strips  of  adhesive  plaster  are  applied  (Figs.  181,  182). 
In  this  manner,  almost  complete  control  of  the  finger  is  assured. 

When,  however,  the  lateral 
angular  deformity  is  pro- 
nounced (Figs.  183,  184),  some 
modification  of  the  apparatus 
may  be  necessary. 

Two  or  three  strips  of  zinc 
or     copper    are    cut    out    2>^ 
inches    long    and    }i    inch    in 
width.     These  are  bent  by  one 
end  around  the  splint,   fitting 
it    snugly   but  yet  capable  of 
being    slipped    backward   and 
forward  along  the  splint.     The 
free    end    is  left  wide    and  is 
bent  up   to  give  the  finger  lateral  support.     This  lateral  support 
may  be  slipped  along   to   the  desired  point  and  effectually  cor- 
rects the  deformity  (Fig.  185). 


Fig.  184. — Crushed  hand.     Lateral  angular 
deformity  of  little  finger.      {Marsee.) 


250 


FRACTURES  OF  THE  EXTREMITIES 


Should  two  or  more  fingers  be  broken,  several  strips  may  be 
used  side  by  side,  but  fastened  to  the  same  flange  of  leather  or 

canvas.  For  two  fingers,  a 
splint  of  double  width  may  be 
fashioned. 

Should  the  thumb  be 
broken,  the  splint  may  be 
heated  and  bent  laterally  in 
proper  shape,  or  an  arm  may 
be  riveted  to  the  ordinary 
strip. 

If  the  fracture  or  disloca- 
tion is  compound,  especially 
if  attended   with   much   dis- 
placement and  difficulty  in  maintaining  reduction,   the   fragment 
should  be  exposed  and  wired,  for  which  one  needs  only  a   small 


Fig.   185. 


-Splint  applied  to  prevent  lateral 
angularity.      {Marsee.) 


Fig.   186. — Suturing    bones    of    finger. 
Drilling.      {Marsee.) 


Fig.  187. — Suturing  bones  of  finger. 
Drawing  suture  through  with  crochet 
hook.      (Marsee.) 


drill  or  awl,  a  fine  steel  crochet-hook  and  chromicized  gut  (Figs. 
186,  187).     Such  is  the  method  taught  by  Marsee. 

The  after-treatment  is  of  importance.     The  splint  will  be  re- 
quired probably  for  two  weeks  or  longer,  but  in  order  to  prevent 


DIAGNOSIS    OF    FRACTURES    OF   TIIK     I II I C II 


251 


stiffness,  passive  motion  should  be  begun  at  the  end  of  the  lirst 
week  and  repeated  every  other  day  at  first.  The  fragments  must  be 
held  in  place  during  the  first  seances.  Under  this  treatment,  the 
stiffness  and  soreness  will  disappear  together. 


FRACTURES  OF  THE  LOWER  EXTREMITY 

The  first  aid  in  these  cases  is  of  special  importance,  as  has  already 
been  indicated.  Even  more  than  elsewhere  the  principle  applies  that 
there  must  be  absolutely  as  little  mo- 
tion as  possible  in  order  that  the  pa- 
tient may  be  spared  pain  and  aug- 
mented shock;  that  the  deformity  may 
not  be  aggravated  and  the  periosteum 
and  other  soft  parts  lacerated;  and  that 
a  simple  fracture  may  not  be  converted 
into  a  compound  one  with  all  the  ad- 
ditional dangers  of  infection.  The 
method  of  lifting  a  patient  so  injured 
has  already  been  described. 

There  are  certain  anatomical  points 
useful  in  the  diagnosis  of  injuries  of 
the  lower  extremities,  certain  land- 
marks that  must  be  kept  clearly  in 
mind;  the  anterior  superior  iliac  spine, 
the  spine  of  the  pubes,  the  ischial 
tuberosity,  the  great  trochanter,  the 
patella  and  condyles  of  the  femur,  the 
tuberosities  and  crest  of  the  tibia,  the 
malleoli. 

There  are  three  lines  useful  in  men- 
suration: Remember  that  the  line  pass- 
ing from  the  anterior-superior  spine  to 
the  ischial  tuberosity  overlies  the  apex 

of  the  great  trochanter.  This  is  Nelaton's  line.  Remember  that 
the  line  dropped  from  the  anterior-superior  spine  to  the  internal 
malleolus    touches    the    inner    border    of    the    patella    (Fig.   188). 


Fig.  188. — Measurement  of 
lower  extremity.  Patient  lying 
on  the  back  looked  at  from  above. 
Position  of  tape,  hands,  and  limbs 
to  be  noted.      {Scudder.) 


252  FRACTURES    OF   THE    EXTREMITIES 

Remember  that  the  Hne  of  the  tibial  crest  prolonged  reaches  the 
second  toe. 

A  routine  method  should  be  practised  in  diagnosis.  Inspection 
reveals  changes  in  position,  deformity  swelling.  Manipulation  de- 
termines mobility,  loss  of  function  and  pain;  palpation  discovers 
changed  relations  in  bony  landmarks  and  displacement  of  fragments; 
mensuration,  shortening  and  deformity.  In  every  case  these  details 
of  examination  should  be  carried  out.  Shortening  is  determined  by 
two  lines  of  measurement. 

If  the  injured  limb  is  shorter  than  the  sound,  measuring  from  the 
anterior-superior  spine  to  the  internal  malleolus,  there  is  a  fracture. 
Now  if  the  distance  from  the  top  of  the  trochanter  to  the  external 
malleoli  are  compared,  shortening  proves  fracture  of  the  anatomical 
neck. 

Fracture  of  the  neck  is  indicated  also  by  changes  in  the  relation  of 
the  trochanter  to  Nelaton's  line. 

FRACTURE  OF  THE  UPPER  END  OF  THE  FEMUR 

Fractures  of  the  upper  end  of  the  femur  have  been  the  subject  of 
much  discussion,  and  various  forms  of  treatment  have  been  recom- 
mended for  imagined  clinical  and  anatomical  varieties.  At  the 
present  time,  nearly  all  surgeons  are  of  the  opinion  that  these  le- 
sions may  be  grouped  under  two  heads,  impacted  and  non-impacted. 
Even  this  division  is  not  important  for  diagnosis,  but  only  for 
prognosis,  since  impaction,  provided  it  is  not  broken  up,  offers  the 
conditions  most  favorable  for  bony  union  (Fig.  189). 

Although  the  differential  diagnosis  is  usually  difficult,  sometimes 
impossible,  yet  the  presence  of  a  fracture  of  some  kind  is  usually 
determined  after  a  little  study.  A  severe  contusion  may  indeed  be 
mistaken  for  fracture,  but  this  is  not  a  serious  error.  On  the  other 
hand,  it  is  a  verv  serious  error  to  mistake  and  treat  a  fracture  about 
the  hip  as  a  contusion.  In  case  of  unresolvable  doubt,  treat  the 
injury  as  a  fracture.     The  diagnosis  is  made  from  several  factors: 

(a)  Pain  is  a  symptom  upon  which  one  cannot  greatly  rely.  It  is 
more  constant  in  impacted  than  non-impacted  fracture  because  of 
the  accompanying  bruises  of  the  soft  parts.  The  pain  is  aggra- 
vated by  pressure  over  the  hip.     Tenderness  and  especially  a  full- 


DIAGNOSIS    OF   FRACTURES    OF   THE    THIGH  253 

ness  in  Scarpa's  triangle  is  frequently  observed.     Pain  with  thick- 
ening of  the  trochanter  means  impaction. 

(b)  Loss  of  function  may  also  be  due  to  contusion;  moreover,  the 
patient  may  be  able  to  walk  with  an  impacted  fracture,  so  that  this 


Fig.   189. — Impacted  fracture  at  the  hip.      Note  lines  of  fracture  in  head,  neck  and 

trochanter. 


symptom  is  no  certain  criterion.     However,  the  patient  is  usually 
unable  even  to  draw  his  heel  upward. 

(c)  Eversion  of  the  foot  is  nearly  always  present  in  some  degree, 
but  is  more  frequently  indicative  of  non-impacted  than  impacted 
fracture,  and  is  due  to  the  weight  of  the  limb. 


2  54  FRACTURES    OF   THE   EXTREMITIES 

(d)  Shortening  is  more  frequently  the  accompaniment  of  im- 
pacted fracture.  It  is  definitely  determined  by  comparing  with 
the  sound  side,  measuring  from  the  anterior-superior  spine  to 
the  interna]  condyle  and  internal  malleolus;  also  by  determining  the 
relation  of  the  trochanter  to  Nelaton's  Hne  (Fig.  i88). 

(e)  Crepitation  is  proof  incontestable  but  rarely  available.  One 
should  make  no  effort  to  elicit  this  symptom,  fearing  to  break  up 
impaction,  which  is  an  accident  much  to  be  deplored,  according  to 
the  usually  accepted  view. 

Senn  (Practical  Surgery)  says  upon  this  point  that  it  is  better  to 
be  satisfied  with  the  probable  evidence  of  fracture.  If  the  surgeon 
in  his  anxiety  to  obtain  a  perfect  diagnosis  moves  the  limb  freely 
in  all  directions,  he  overcomes  impaction,  rupturing  the  cervical 
ligaments,  demonstrating  beyond  all  doubt  the  existence  of  the 
fracture  and  at  the  same  time  effectually  destroying  all  hope  of 
reunion.  As  Senn  suggests,  a  useless  limb  is  certainly  a  high  price 
to  pay  for  a  perfect  diagnosis. 

Age  is  an  important  feature  in  differential  diagnosis.  In  the  el- 
derly the  injury  is  more  likely  to  be  intra-capsular  with  or  with- 
out impaction:  In  the  middle  age  extra-capsular,  impacted  frac- 
ture is  the  more  likely;  and  in  the  child  or  adolescent,  separation  of 
the  epiphysis  is  much  the  more  frequent. 

Oftentimes  the  X-ray  alone  can  determine  the  lines  of  fracture, 
and  again  it  will  often  unexpectedly  reveal  a  fracture  in  the  young 
in  whom  contusion  is  the  favored  diagnosis. 

■  The  treatment  resolves  itself  into  two  lines  of  procedure,  de- 
pending upon  whether  or  not  the  fracture  is  impacted.  In  either 
case  the  treatment  should  be  modified  by  the  age  and  constitution  of 
the  patient.  Confinement  on  the  back  may  be  fatal  in  the  aged, 
and  it  is  imperative  in  such  cases  to  give  the  patient  more  freedom. 
This  imperfect  immobilization  may  eventually  result  in  an  imperfect 
union,  but  one  must  be  consoled  by  the  reflection  that  a  fatal  attack 
of  hypostatic  pneumonia  may  have  been  prevented.  In  the  case 
of  the  aged,  therefore,  the  main  object  is  to  get  the  patient  on  his  feet 
as  soon  as  possible.  For  the  first  week  the  limb  should  be  fixed 
with  sand-bags  and  massaged  daily.     After  that  a  plaster  spica  ex- 


TREATMENT    OF   FRACTURES    OF   THE   THIGH  255 

tending  halfway  to  the  knee  may  be  applied  and  the  patient  per- 
mitted to  get  about  with  crutches. 

In  the  case  of  undisturbed  impaction  in  adults,  the  treatment  is 
of  the  simplest  form.  The  patient  is  placed  on  a  smooth  mattress, 
the  limb  supported  by  sand-bags  or  perhaps  light  extension  applied, 
and  systematic  massage  early  instituted.  Union  may  occur  with 
no  treatment  at  all.  I  recall  the  case  of  a  man  of  sixty  who  fell  in 
the  street  with  what  was  supposed  to  be  an  apoplectic  stroke.  He 
was  carried  to  his  home  to  die  but  it  was  soon  discovered  that  the 
conditions  were  not  so  serious  but  it  was  still  supposed  that  he  was 
paralyzed  in  one  leg.  After  two  months  in  bed  he  was  able  to  get 
about  with  crutches  but  he  had  a  very  painful  hip.  A  year  later 
he  was  still  on  crutches  and  was  brought  to  the  hospital  for  examina- 
tion and  the  X-ray  showed  that  he  had  suffered  an  impacted  frac- 
ture of  aggravated  form.  He  had  marked  eversion  and  shortening 
but  a  firm  union.  Now  a  year  later  he  still  walks  lame  but  without 
the  aid  of  a  cane. 

Union  with  deformity  and  large  loss  of  function  may  be  secured 
by  doing  little  or  nothing. 

Restoration  of  function  implies  restoration  of  form  and  this 
accompHshed  by  breaking  up  the  impaction,  abducting  the  limb 
and  fixing  it  w^ith  a  plaster  spica. 

Whitman  has  formulated  a  technic:  Unless  the  condition  of  the 
patient  forbids,  he  proceeds  gently  to  break  up  the  impaction 
under  anesthesia.  The  limb  is  reduced  by  extension  and  gradual 
abduction  to  an  angle  of  forty-five  degrees,  in  the  meantime  sup- 
porting the  upper  end  of  the  femur  and  rotating  the  leg  inward. 

In  this  position,  the  limb  is  w^ell  covered  with  cotton  batting,  all 
the  bony  points  especially  well  protected  and  a  flannel  bandage 
smoothly  applied.  A  plaster  spica  is  now  applied  extending  from 
the  lower  ribs  to,  and  including,  the  foot.  The  plaster  fits  the  pelvis 
snugly  and  is  molded  close  to  the  trochanter  and  posterior  aspect 
of  the  joint.  It  is  also  molded  to  the  patella  and  condyles,  and  to 
the  foot  to  prevent  rotation.  This  dressing  permits  the  patient 
to  rise  up  in  bed  without  much  discomfort. 

The  advantage  of  abduction  is  that  it  makes  the  capsule  tense 
and  thus  aligns  the  displaced  fragments;  that  it  directs  the  surface' 


256  FRACTURES  OF  THE  EXTREMITIES 

of  the  outer  fragment  toward  that  of  the  inner;  that  it  relaxes  the 
muscles  that  produce  distortion  by  their  traction;  that  it  apposes 
the  trochanter  to  the  side  of  the  pelvis  and  thus  checks  upward 
displacement.  Repair  in  these  fractures  is  slow  and  can  hardly  be 
completed  within  a  year;  thus  prolonged  after-treatment  is  nec- 
essary to  restoration  of  function  (J.  A.  M.  A.,  Feb.  20,  1909). 


Fig.   190. — Non-impacted  fracture  of  the  anatomical  neck  of  the  femur;  so  called 

intracapsular  fracture. 

If  the  case  is  one  of  non-imp  action  (Fig.  190)  with  much  shortening 
and  the  condition  of  the  patient  will  admit  Senn  advises  reduction 
followed  by  prolonged  immobilization  in  plaster  extending  from  the 
"waist  to  the  toes  and  which  is  fenestrated  over  the  trochanter  for  the 


TREATMENT   OF   FRACTURES    OF   THE   THIGH  257 

purpose  of  applying  lateral  pressure.  The  lateral  pressure  he  regards 
as  essential  to  good  union.  But  the  plaster  cast  is  difficult  to  apply. 
It  is  necessary  that  there  be  some  sort  of  pelvis  support  and  strong 
traction  must  be  continued  until  the  plaster  is  hard. 

The  limb  and  trunk  are  encased  in  glazed  cotton  or  what  is  much 
better  drawers  of  stockinet.  Three  layers  of  plaster  roller  are 
run  on  from  the  thorax  to  the  toes.  The  plaster  splint  is  then 
molded  to  the  outer  side  of  the  limb,  pelvis,  and  trunk,  and  fresh 
layers  of  the  roller  applied.  The  plaster  is  molded  very  carefully 
to  the  bony  points  as  by  this  means  the  dressing  secures  an  effective 
grip.  The  plaster  splint  consists  of  ten  or  twelve  layers  of  crino- 
line, cut  in  two  sections,  the  first  extends  from  the  thorax  down  to 
the  toes  along  the  outer  side  and  cut  to  a  pattern  which  covers  half 
the  limb,  the  second  section  is  wide  enough  to  extend  from  the 
trochanter  to  the  level  of  the  ensiform  and  long  enough  to  reach 
two-thirds  about  the  body.  It  is  fastened  to  the  first  section  in 
the  manner  of  a  cross. 

FRACTURE  OF  THE  SHAFT  OF  THE  FEMUR 

In  this  fracture  the  lower  fragment  is  nearly  always  displaced 
forward  and  backward.  If  the  fracture  has  been  produced  by  di- 
rect force,  it  may  be  transverse,  but  this  is  the  exception.  The 
diagnosis  is  simple:  shortening,  eversion,  loss  of  function. 

Manipulation  is  unnecessary  and  decidedly  to  be  avoided,  not 
only  that  the  patient  may  be  spared  the  pain,  but  also  that  the 
trauma  may  not  be  aggravated,  the  periosteum  torn,  the  muscles 
bruised,  the  vessels  injured. 

Reduction. — This  must  not  be  begun  till  all  the  dressings  are 
quite  ready.  General  anesthesia.  One  assistant  grasps  the  thigh 
with  both  hands  near  the  pelvis;  the  other  assistant,  the  foot  and 
lower  third  of  the  leg.  As  they  make  traction  and  counter-trac- 
tion the  surgeon  manipulates  the  fragments.  The  traction  must 
be  prolonged  as  these  strong  muscles  relax  only  gradually. 

When  the  fracture  is  quite  oblique  and  the  pointed  extremities 
are  caught  in  the  soft  parts,  a  little  patience  will  be  required  to  free 
the  fragments.     To  effect  this,  slight  rotation  and  oscillation  must 
be  added  to  extension  and  abduction. 
17 


258  FRACTURES    OF    THE   EXTREMITIES 

How  will  one  know  that  reduction  is  complete? 

(i)  These  points  must  exactly  correspond  when  the  two  limbs  are 
placed  side  by  side:  the  upper  border  of  the  two  patellae,  the  lower 
border  of  the  two  internal  malleoli,  the  two  soles. 

(2)  The  limbs  must  be  the  same  length  by  measurement  from 
the  anterior-superior  ilica  spine  to  the  inner  malleolus. 

(3)  The  line  dropped  from  the  iliac  spine  to  the  malleolus  must 
touch  the  inner  border  of  the  patellae. 

Dressing. — Many  forms  of  splints  are  described;  many  of  them 
complex;  all  effective  in  some  degree.  Whatever  the  form  employed, 
the  limb  must  be  frequently  measured  and  the  patient's  general  con- 
dition kept  under  close  watch.  Scudder  highly  recommends  a 
modified  Buck's  extension.  ]\Iany  are  more  successful  with  the 
plaster  cast. 

Lejar  recommends,  as  the  simplest  in  emergency  practice,  the 
dressing  of  Tillaux.  From  a  roll  of  adhesive  plaster  are  cut  eight  or 
nine  strips  i3^^  inches  wide,  and  long  enough  to  extend  from  the 
level  of  fracture  down  the  side  of  the  limb,  over  the  sole  of  the 
foot  after  the  manner  of  a  stirrup,  and  up  the  opposite  side  of  the 
leg  to  the  level  of  the  fracture. 

Begin  by  applying  one  of  the  strips  in  the  direction  indicated. 
Next  slip  a  strip  transversely  under  the  thigh,  another  under  the  calf, 
and  a  third  under  the  ankle,  and  make  one  circular  turn  of  each. 
Next  apply  a  second  longitudinal  strip  slightly  overlapping  the  first; 
follow  with  another  turn  of  each  circular  strip,  and  so  on.  In  this 
manner  the  strips  are  given  a  firm  attachment. 

Every  point  of  contact  of  the  adhesive  must  be  perfectly  smooth. 
Every  longitudinal  strip  must  extend  the  same  distance  as  its  fellows 
below  the  sole  in  order  that  the  extension  weight  shall  make  uniform 
traction  on  all  the  components  of  the  stirrup. 

A  cord  is  fastened  to  the  stirrup,  passed  through  a  pulley  at  the 
foot  of  the  bed  and  a  weight  of  5  or  10  pounds  attached.  If  a 
pulley  is  not  obtainable,  a  hole  can  be  cut  in  the  foot  of  the  bed  if  it 
is  wooden;  or  the  cord  may  work  over  broom  handle  attached  to  an 
iron  bedstead.  The  weight  must  be  increased  in  the  case  of  the 
muscular  or  in  the  case  of  a  very  oblique  fracture. 

A  case  will  illustrate  the  difficulties  which  may  attend  reduction  in 


TREATMENT   OF   FRACTURES    OF   THE   TinOII 


259 


these  cases  of  fracture  of  middle  of  the  shaft.  A  young  man  caught 
and  crushed  under  a  falling  load  of  telegraph  poles  was  brought  to  the 
City  Hospital  in  full  shock.  It  scarcely  seemed  possible  for  him  to 
survive.  It  seemed  certain  that  he  must  have  had  grave  internal 
injuries  though  there  was  no  direct  evidence  to  that  effect.  The 
shock  gradually  subsided  and  no  further  evidence  of  visceral  compli- 


FiG.  191. — Supracondylar  fracture  of  the  femur. 


cation  arising,  attention  was  directed  to  his  fractured  femur,  which 
was  broken  about  the  middle.  Efforts  at  reduction  were  painless 
but  wholly  ineffectual  in  securing  a  coaptation.  Continuous  exten- 
sion was  applied  but  after  two  days  an  X-ray  examination  showed  the 
fragments  still  separated  and  overlapping. 

Later  an  open  operation  found  the  broken  ends  interlocked  with 
muscular  tissue.  With  some  effort  they  were  freed,  coapted  and 
plated.  Some  suppuration  delayed  repair,  but  he  finally  recovered 
with  a  good  limb. 


26o 


FRACTURES  OF  THE  EXTREMITIES 


SUPRACONDYLAR  FRACTURES 

These  derive  their  importance  from  the  frequency  with  which 
the  fragments  involve  the  knee-joint  or  the  structures  in  the  popHteal 
space,  and  from  the  difficulty  of  maintaining  coaptation.  Both 
these  characteristics  depend  upon  the  obliquity  of  the  fracture  which 
usually  extends  from  behind  downward  and  forward  (Fig.  191). 
The  complications  must  be  treated  on  general  principles. 

The  fixation  may  be  any  of  the  means  just  described  for  frac- 
tures of  the  shaft.  In  this  case  as  in  any  very  oblique  fracture, 
flexion  of  knee  and  hip  seem  specially  indicated. 


/     w     ^    HA  '  *"'   >^*/^ 

Fig.  192. — Hodgen  splint  for  fractured  thigh.     {Moullin.) 


Hennequin's  apparatus  secures  an  efficient  extension,  combined 
with  flexion  of  the  hip  and  knee  and  permits  the  patient  to  sit  up. 
Downey,  of  Gainesville,  Ga.,  has  thought  out  a  device  which  involves 
the  same  principles  as  the  Hennequin  apparatus  but  is  simpler  in 
application.  As  Downey  remarks  (American  Jour.  Surg.,  March, 
191 5)  the  dressing  aims  to  secure  at  once  the  position  of  the  Esmarch, 
Smith,  Hodgen  (Fig.  192),  or  Cabot  apparatus;  the  extension  of  the 
Buck  apparatus;  the  fixation  of  plaster  of  Paris.  This  is  accom- 
plished by  means  of  a  double  angular  plaster-of-Paris  splint. 


TREATMENT    OF    FRACTURES    OF    THE    TinCH  26 1 

The  mode  of  application  (briefly)  is  this:  Secure  counter- traction 
by  a  padded  sheet  passed  between  the  legs  and  brought  well  up 
against  the  perineum;  traction,  by  grasping  the  leg  above  the  ankle 
with  one  hand,  under  the  knee  with  the  other.  A  plaster  cast  is 
applied  from  the  toes  to  just  above  the  knee,  which  is  well  flexed. 
Now  secure  coaptation. 

Next  apply  the  second  section  of  the  cast,  beginning  at  the  upper 
border  of  the  first  and  carrying  the  roller  in  the  ordinary  manner 
up  to  the  ensiform,  all  the  while  maintaining  the  traction  with  hip 
well  flexed.  Strengthen  the  outer  side  of  the  cast  at  the  hip-joint 
by  up-and-down  folds  of  the  roller  or  by  metal  splints.  Split  the 
splint  if  constriction  is  feared. 

AFTER-TREATMENT  OF  FRACTURE  OF  THE  FEMUR 

Whatever  the  form  of  treatment,  union  will  scarcely  ever  occur 
short  of  six  or  seven  weeks.  Whether  union  has  occurred  or  not 
can  be  determined  by  manipulation  of  the  fragments,  and  if  they 
are  well  fixed  the  patient  should  be  encouraged  to  use  his  crutches, 
but  he  should  not  be  permitted  to  bear  his  weight  on  the  injured  leg 
short  of  three  months.  And  even  then  only  if  he  can  lift  his  leg 
without  pain,  if  the  callus  is  rounded,  and  of  moderate  volume,  and 
if  pressure  does  not  produce  pain. 

Attention  should  be  given  the  selection  of  the  crutches  which 
should  just  reach  to  the  axilla  and  the  cross  piece  for  the  hand  should 
not  be  too  low  lest  undue  pressure  fall  on  the  musculo-spiral  nerve. 
The  edema,  usually  moderate,  disappears  with  increased  use  and 
likewise  the  muscular  atrophy. 

The  knee,  nearly  always  stiffened,  gradually  regains  its  move- 
ments. Shortening  in  some  degree  is  inevitable  but  in  a  general  way 
it  may  be  said  that  in  the  course  of  time  the  functional  cure  is 
complete. 

FRACTURES    OF    THE    FEMUR    IX    CHILDREN 

Fractures  of  the  shaft  present  nothing  special  in  the  matter  of 
diagnosis. 

The  treatment  of  choice  is  the  plaster  spica  much  more  easily 
applied  than  in  the  case  of  adults.     It  must  be  molded  carefully  and 


262  FRACTURES    OF    THE    EXTREMITIES 

special  precautions  must  be   taken  to  strengthen   the  cast  in   the 
region  of  the  groin. 

The  cast  may  be  left  off  after  a  month.  In  the  case  of  the  new- 
born the  best  tTea,tmtnt  is  hy  vertical  extension.  In  this  portion  the 
infant  can  be  easily  kept  clean  which  is  the  most  important  part  of 
the  treatment.  The  fracture  in  the  great  majority  of  cases  involves 
the  upper  third  and  requires  much  more  force  to  effect  a  reduction 
than  might  be  expected. 

The  vertical  extension  is  accomplished  by  applying  adhesive  plaster 
to  both  limbs  in  such  manner  as  to  make  a  small  stirrup  for  either 
foot  to  which  cords  are  attached  and  passed  through  pulleys  and 
fastened  to  the  cross  bar  over  the  bed.  A  weight  sufficient  to  keep 
the  legs  straight  in  the  vertical  position  is  applied. 

A  very  light  plaster  roller  incases  the  injured  limb  and  which 
need  not  be  changed  till  union  is  fairly  firm  which  will  usually  be 
within  two  weeks  (Fig.  193). 

Judet  particularly  recommends,  in  these  cases,  treatment  in  the 
horizontal  position  without  extension,  using  for  fixation  a  gutta- 
percha splint.  The  splint  is  cut  out  of  a  sheet  of  gutta-percha  at 
least  6  mm.  thick  the  upper  part  wide  enough  to  encircle  two-thirds 
of  the  trunk  from  the  nates  to  the  lower  ribs. 

The  lower  portion  is  as  long  as  the  limb  and  so 
tapered  as  to  cover  two-thirds  of  the  circumference 
of  the  entire  limb  forming  in  other  words  a  posterior 
splint. 

This  gutta-percha  splint  is  next  soaked  in  hot 
water  and  when  soft  is  molded  to  fit  the  trunk  and 
thigh  and  leg  posteriorly,  next  dipped  in  cold  water 
and  when  hardened  is  lined  with  absorbent  cotton 
and,  when  the  fracture  is  reduced,  this  splint  is  ap- 
plied and  held  on  with  a  roller  bandage.     A  splint 

Fig.  193.— Bry-      ^.  .  r     i  •    i 

ant's  vertical  ex-    Similarly  molded  to  the  anterior  part  of  thigh  may 
tension  for  frac-    ]^q  added.     This  drcssiug  mav  be  removed  everv  day 

ture    of   femur  in  ...  ^  ^  •     ^        ^'        ^  • 

children.  whcn  the  infant  has  his  bath,  taking  care  to  support 

the  limb  in  the  interval. 
Separation  of  the  epiphysis  of  the  lower  end  of  the  femur  is  another 
injury  which  must  not  be  forgotten  (Fig.  194). 


SEPARATION    OF   THE   EPIPHYSIS 


263 


A  youth  of  sixteen  was  brought  to  the  City  Hospital  for  an  ampu- 
tation of  the  thigh.  He  had  a  greatly  swollen  and  painful  knee,  of 
long  duration  and  upon  which  a  great  variety  of  treatment  had  been 
applied  on  various  hypotheses.     A  careful  manual  and  X-ray  ex- 


FiG.   194. — Separation  of  epiphysis  of  lower  end  of  femur;  below  is  shown  the 
epiphysis  of  the  tibia  in  its  normal  relation. 


amination  developed  the  presence  of  a  bony  mass  projecting  into 
the  popliteal  space  from  the  inner  side  of  the  knee  and  the  patella 
lay  upon  the  outer  aspect  of  the  limb. 

The  conditions  manifestly  insured  a  permanently  useless  limb. 


264  FRACTURES    OF    THE   EXTREMITIES 

There  was  a  history  of  a  fall  from  a  bicycle  with  injury  to  the  knee, 
supposed  to  be  a  bruise.  Nevertheless  he  had  never  born  his  weight 
on  the  limb  from  that  time. 

A  diagnosis  of  separation  and  displacement  of  the  epiphysis 
was  made  and  operation  ad\dsed.  A  semilunar  incision  below 
the  patella,  followed  by  section  of  its  tendon,  exposed  the  joint  and 
revealed  the  epiphysis  united  to  the  shaft  in  a  distorted  position. 
The  spongy  tissue  w^as  easily  di\'ided,  the  fibrous  connections 
loosened,  the  raw  surfaces  of  bone  trimmed  and  the  condylar  end 
brought  back  into  something  like  its  normal  position,  and  wired. 

The  patella  w^as  with  some  difficulty  shifted  into  its  proper  groove 
and  the  tendon  reunited.  The  limb  was  fixed  in  plaster  and  after 
three  weeks  passive  motion  was  begun.  Now^  six  months  after  the 
operation  the  outHnes  of  the  knee  are  practically  normal,  there  is 
slight  motion  and  the  patient  w^alks  easily  with  only  the  help  of  a 
cane. 

Usually  the  condyles  are  displaced  forward  and  laterally  and  the 
shaft  projects  toward  the  popliteal  space.  The  change  in  the 
landmarks,  the  great  swelling  about  the  joint,  the  deviation  in  the 
axis  of  the  limb  is  sufficient  for  a  diagnosis.  The  treatment  consists 
in  replacement  by  strong  traction  with  manipulation  of  the  fragments 
under  anesthesia,  followed  by  fixation  in  plaster. 

Sometimes  forced  flexion  as  in  the  case  of  the  elbow  will  succeed 
and  after  two  wrecks  extension  must  be  begun. 

Finally  a  few  cases  will  resist  reduction  and  will  require  immediate 
operation. 

FRACTURE    OF    THE   PATELLA 

Fractures  of  the  patella  are  comparable  with  those  of  the  ole- 
cranon. They  may  be  transverse,  such  are  usually  fractures  result- 
ing from  indirect  force;  or  they  may  be  vertical,  or  oblique,  or 
multiple  (Figs.  195,  196). 

There  are  two  obstacles  to  osseous  reunion:  the  action  of  the 
quadriceps  extensor  and  the  intervention  of  the  patellar  fascias,  pre- 
venting exact  coaptation.  In  spite  of  these  unfavorable  circum- 
stances, there  is  generally  some  form  of  fibrous  reunion  unless  the 
fragments  are  very  widely  separated  (Fig.  197). 


FRACTURES    OF   THE   PATELLA 


265 


The  treatment  of  the  present  time  is  by  one  of  two  methods — mas- 
sage or  suture.     If  the  fracture  is  transverse,  with  very  little  separa- 


Fig.  195. — Transverse  frac- 
ture of  patella.     (Moullin.) 


Fig.   i'jO. — Comminuted      frac- 
ture of  patella.     (Moullin.) 


tion,  and  the  conditions  are  not  favorable  for  an  aseptic  operation, 
massage  may  be  expected  to  give  a  good  functional  result.  If  the 
separation  is  considerable,  massage  ^.r-^-a-^ 

will  still  give  a  better  result  than  /  j^p  ;.-;  '<^^^  /; 

any  splints. 

In  any  case  suturing  is  the  ideal 
form,  although  the  ideal  cannot 
always  be  attained.  Again,  every 
compound  fracture  should  be  im- 
mediately sutured.  J.  H.  Ford, 
whose  experience  with  these  frac- 
tures has  been  large,  describes  his 
method  of  procedure  in  ordinary 
fracture  (Ind.  Medical  Jour.,  July, 
1907). 

In  the  non-operative  cases  he  be- 
gins by  elevating  the  limb  for  sev- 
eral days  to  relax  the  quadriceps. 
If  there  is  effusion  he  bandages 
lightly  w4th  a  flannel  roller,  or  if 
the  hemarthrosis  is  marked,  a  firm 
constriction  is  practised  or  ice-bags 
applied. 

As  soon  as  the  acute  symptoms 
have  subsided,  which  is  after  three,  to  five  days,  massage  is  insti- 
tuted and  daily  applied.      Begin  with  gentle  constriction  of  the 


Fig.  197. — Fracture  of  the  patella. 
Showing  separation  of  fragments  and  dis- 
tension of  the  synovial  sac,     {Moullin.) 


266  FRACTURES    OF   THE   EXTREMITIES 

joint  with  the  hands  by  an  upward  movement,  and  ending  with 
more  vigorous  pressure  of  the  sides  of  the  patella  and  the  joint.  In 
the  intervals  the  limb  should  be  maintained  on  a  posterior  splint. 
After  from  four  to  six  weeks  of  this  treatment,  he  immobilizes  the 
joint  in  a  plaster  cast,  preferably  for  two  weeks  more,  and  subse- 
quently, he  recommends  a  morning  and  evening  massage  and 
flannel  bandaging  until  the  functions  are  practically  restored. 


Fig.   198. — Suture  of  patella.      Method  of  drilling  and  passing  sutures.      (Labey.) 

The  operative  treatment  is  not  simple,  yet  by  no  means  beyond 
the  skill  of  anyone  who  knows  how  to  secure  asepsis  and  to  apply 
a  bone  suture.  Begin  w^ith  a  semilunar  incision,  concave  upward, 
well  below  the  line  of  fracture  and  reaching  to  either  border  of  the 
patella.  Raise  the  cutaneous  fl^p  and  expose  the  patella.  The  artic- 
ulation is  carefully  wiped  out  and  freed  of  all  fragments  and  clots. 


FRACTURES    OF    THE    PATELLA 


267 


Fixing  the  upix^T  ficigiiicnl  by  appropriate  forceps,  two  slight  in- 
cisions are  made  in  the  periosteum  at  the  points  where  the  drill  is 
expected  to  enter.  Two  tunnels  are  now  drilled  from  above,  emerg- 
ing on  the  face  of  the  fracture  well  outside  the  line  of  the  cartilage. 
The  sutures  are  drawn  through  these  openings  and  the  process  is 
repeated  in  the  lower  fragment,  but  great  care  must  be  used  in  se- 
curing a  correspondence  with  the  first  two  drill  holes  or  the  coapta- 
tion will  be  imperfect  (Fig.  1 98) .  By  traction  on  the  sutures  the  frag- 
ments are  brought  together,  and  great  care  is  necessary  to  avoid 


Fig.   199. — Suture  of  patella.     Completing  repair  by  suture  of  periosteum 
and  fibrous  coverings.     (Labey.) 


including  shreds  of  fascia.  The  sutures  are  tied,  twisted  firmly,  and 
pressed  down  upon  the  bone.  The  periosteum  and  fibrous  coverings 
are  next  sutured  with  catgut  (Fig.  199). 

Ford  prefers  not  to  wire,  but,  after  approximation,  sutures  the 
lateral  fascia  with  No.  3  forty-day  chromicized  catgut  and  the 
aponeurosis  in  front  with  No.  i.  A  No.  i  forty-day  suture,  18  inches 
long,  is  then  threaded  on  a  strong,  half-curved  needle  which  is  en- 
tered into  the  aponeurosis  just  above  and  on  a  line  with  the  outer 


268  FRACTURES    OF   THE    EXTREMITIES 

edge  of  the  patella  and  follows  the  upper  border  of  the  patella  to  the 
inner  side  where  it  emerges;  is  re-entered  and  carried  down  the  inner 
side;  again  around  the  lower  fragment,  passing  through  the  ligamen- 
tum  patella  and  emerging  at  its  outer  border.  This  retention  suture 
is  now  tied  tightly  at  this  last  point  of  emergence  (Fig.  2co).  The 
skin  wound  is  next  repaired  ^^'ithout  drainage.  The  limb  is  subse- 
quently immobilized  for  two  weeks  when  massage  is  to  be  begun. 


Fig.   200. — Fracture  of  patella.      Circular  suture.      (Labey.) 

Ford  lays  do^Ti  these  rules  respecting  the  treatment  of  simple 
transverse  fracture: 

(i)  Operative  treatment  should  never  be  undertaken  except  under 
the  best  conditions  for  maintaining  asepsis. 

(2)  Even  under  aseptic  conditions  not  every  case  should  be  oper- 
ated on,  but  only  those  in  which  the  separation  is  at  least  M 
inch  and  the  "reserve  extension  apparatus''  is  compromised  by 
lateral  tears. 

(3)  Operative  treatment  fulfills  all  the  indications  in  a  degree 
which  the  non-operative  treatment  can  only  partially  achieve. 

(4)  Early  massage  favors  complete  restoration  of  function  and 
should  be  used  in  all  cases. 


FRACTURES   OF   TIBIA  AND  FIBULA 


269 


(5)  In  operative  treatment  i)i)en  arthrotumy  sliould  be  practised. 

(6)  Absorbable  suture  material  applied  only  to  the  soft  parts  is 
sufficient  in  nearly  every  case. 

FRACTURES  OF  THE  LEG 

Fractures  of  the  leg  present  many  variations,  but  the  prognosis 
and  the  difficulties  of  treatment  depend  chiefly  upon  whether  the 
fracture  is  transverse  or  oblique.     If  transverse  there  is  usuallv 


i 

^Hm^  ^H 

Fig.  201. — Longitudinal  fracture  of  tibia  and  oblique  fracture  of  fibula. 

slight  displacement,  easily  reduced  and  easily  maintained;  if  oblique 
there  may  be  much  displacement  which  is  difficult  to  reduce  and  hold, 
and  often  results  in  much  loss  of  function. 

Transverse  fractures  more  commonly  are  due  to  direct  lorce  and 
the  lesion  corresponds  to  the  application  of  force.     Oblique  fractures 


270 


FRACTURES    OF   THE   EXTREMITIES 


are  more  commonly  due  to  indirect  force  and  the  two  bones  give  way 
at  their  point  of  least  resistance,  which  in  the  case  of  the  tibia  is  at 
the  junction  of  the  middle  and  lower  third;  in  the  case  of  the  fibula 
in  the  upper  third.  In  general,  displacement  is  always  favored  if 
both  bones  are  fractured  (Fig.  201). 

The  diagnosis  of  these  injuries  usually  offers  but  little  difficulty. 
The  deformity,  loss  of  function,  pain  and  crepitus,  and  preternatural 


Fig.  202. — Fracture  of  upper  end  of  tibia,  involving  the  joint. 


mobility  leave  but  little  doubt  except  when  the  injury  is  at  the  upper 
end,  and  where  the  joint  may  be  involved  (Fig.  202),  or  when  the 
fibula  alone  is  fractured.  A  useful  test  for  fracture  of  the  fibula  is 
compression  of  the  two  bones  some  distance  from  the  suspected 
site;  the  pain  occurs  not  at  the  point  of  pressure  but  at  the  point 
of  fracture. 

If  there  is  great  displacement  of  the  fragments  the  deformity  is 
pronounced,  the  foot  turns  to  the  outside,  the  fragments  may  be 


FRACTURES   OF   THE   TIBIA 


271 


felt  projecting  under  the  skin  which  soon  becomes  greatly  discolored 
and  often  covered  with  blebs. 

Reduction. — The  assistant  grasps  the  leg  at  the  knee,  the  surgeon 
grasps  the  foot  with  one  hand  and  the  heel  with  the  other;  or  two 
assistants  may  make  the  necessary  traction  while  the  surgeon  man- 
ipulates the  fragments. 

What  is  the  test  of  good  coaptation?  The  crest  of  the  tibia  forms 
a  continuous  line  without  projections  or 
depressions.  This  line  prolonged  strikes 
the  first  metacarpal  space.  The  internal 
surface  of  the  tibia  is  smooth  and  uniform. 
With  the  foot  at  a  right  angle,  a  line 
dropped  from  the  anterior-superior  iliac 
spine  to  the  inner  border  of  the  great  toe 
touches  the  inner  border  of  the  patella. 


Fig.   203. — Cloth  cut  to  fit  the  limb  and  notched  at  the  ankle  in  order  to  be  more  easily 
adjusted  to  the  malleoli  when  it  is  soaked  with  plaster.     (Lejars.) 

The  reduction  is  by  no  means  so  simple  as  it  seems  and  even  when 
easily  accomplished  may  be  diflficult  to  maintain  while  the  dressing 
is  applied.  A  maneuver  which  often  succeeds  without  the  use  of 
great  force  is  that  which  is  practiced  in  the  open  operation.  The 
limb  is  flexed  at  the  line  of  fracture  and  the  two  fragments  brought 
into  contact  along  the  line  of  their  lower  borders.  This  affords  a 
leverage  when  traction  is  applied.  Coincident  with  traction  the 
limb  gradually  straightens  and  the  lower  fragment  adapts  itself  to 
the  upper. 


272 


FRACTURES    OF   THE   EXTREMITIES 


Dressing. — ^This  will  vary  somewhat,  depending  upon  the  situation 
and  tendency  to  displacement.  In  the  simple  case  of  fracture  of  the 
shaft  of  the  tibia,  following  the  counsel  of  Stimson,  it  is  best  to  put 
the  patient  to  bed  with  the  limb  in  a  Volkmann  splint  for  about  a 
week  until  the  swelling  has  subsided,  and  then  to  encase  it  in  plaster 
of  Paris.  Immediate  application  of  the  plaster  of  Paris  is  objec- 
tionable because  it  cannot  be  determined  from  the  first  whether  the 


Fig.  204. — Plaster  splint  applied  and  fixed  with  roller  plaster  bandage.     Note  manner  of 
supporting  limb  and  applying  roller.      (Lejars.) 


swelling  will  increase  or  diminish.  The  two  dressings  may  be  com- 
bined by  applying  a  plaster  splint  from  the  first,  and  this  we  prefer. 
Lejars  describes  the  construction  of  such  a  splint.  He  measures 
from  the  middle  of  the  thigh  do\^Ti  to  the  heel  and  up  the  sole  to  the 
toes,  and  this  will  be  the  length  of  the  sixteen  layers  of  crinoline  from 
which  the  splint  is  to  be  made.  Take  the  circumference  of  the  thigh, 
the  knee,  the  middle  of  the  leg,  the  ankle,  and  transfer  the  measures 
to  the  crinoline  which  was  cut  wide  enough  in  the  first  place  to  en- 


FRACTURES   OF   THE   TIBIA 


^n 


circle  the  thigh.  Connect  the  ends  of  these  cross  measurements  with 
a  chalk  line  and  in  this  manner  one  forms  a  rough  outline  of  the  limb, 
and  the  bandage  is  cut  accordingly.  Some  prefer  to  apply  the  mate- 
rial to  the  sound  limb  and  mark  it  off  in  that  way. 

Opposite  the  ankle  a  notch 
should  be  cut  in  the  dressing, 
running  toward  the  heel,  that 
the  dressing  may  be  more 
readily  fitted  (Fig.  203).  This 
is  soaked  wdth  liquid  plaster 
and  applied  while  the  extension 
and  counterextension  are  main- 
tained and  the  foot  fixed  at  a 
right  angle.  This  tension  must 
not  be  relaxed  until  the  plaster 
has  hardened.  The  dressing  is 
completed  by  applying  a  roller 
bandage  (Fig.  204). 

While  the  plaster  is  harden- 
ing it  is  necessary  to  test  the 
reduction  by  the  measurements 
indicated  and  to  readjust  the 
alignment,  the  assistant  must 
be  warned  not  to  carry  the  foot 
forward  in  making  traction  lest 
angulation  occur. 

The  plaster  must  be  well 
molded  about  the  knee  and  the 
ankle  in  order  that  shortening 
may  not  recur. 

Oblique  fractures  (Fig.  205),  hard  to  hold,  are  Jikely  to  be  near 
the  lower  end.  The  quadriceps  extensor  pulls  the  upper  fragment 
forward,  and  the  gastrocnemius  pulls  the  lower  fragment  backward. 
The  special  form  of  dressing  which  Scudder  recommends  for  this 
form  of  fracture  is  made  by  a  combination  of  plaster  and  adhesive 
strips.  The  adhesive  strips  are  applied  as  indicated  (Fig.  206).  A 
thick  roll  of  sheet  w^adding  is  applied  to  the  sole  of  the  foot,  and  a 
18 


Fig    205  — Typical  oblique  fracture  of  the 
shaft  of  tibia. 


74 


FRACTURES    OF    THE    EXTREMITIES 


plaster  bandage  applied  from  the  toes  to  above  the  knee.  A  buckle 
looking  upward  is  incorporated  in  the  plaster  just  above  the  level  of 
the  knee.     A  slit  is  left  in  each  side  at  the  ankle  for  the  lower  exten- 


sion    strips     to    come    through. 


a. 


h 


When  the  plaster  has  hardened, 
I  the  upper  extension  strips  are 
■l  fastened  in  the  buckles  and  the 
lower  extension  strips  pulled  out 
through  the  slits  and  drawn  tight 
around  the  foot  piece  after  the 
wadding  at  the  sole  has  been  re- 
moved. The  purpose  of  this 
arrangement  is  to  maintain  ex- 
tension. 

Whatever  form  of  dressing  is 
used  the  limb  must  be  watched 
to  see  that  no  displacement  oc- 
curs. While  a  simple  fracture 
usually  firmly  unites  within  six 
weeks,  those  which  have  been  hard 
to  keep  reduced  will  remain  weak 
much  longer.  As  soon  as  there  is 
sufficient  union  to  prevent  dis- 
placement, then  massage  should 
be  begun  and  continued  till  the 
limb's  functions  are  restored. 

Whether  it  is  safe  to  leave  off 
the  dressing  is  to  be  determined 
largelv  bv  the  character  of  the 
callus  which  should  be  fusiform 
and  of  moderate  volume.  The 
pain  on  pressure  and  movement 
must  be  slight  and  of  course  there 

must  be  no  mobility  of  the  fragments. 

Crutches  must  be  used  to  begin  with  and  light,  easily  removable 

splints  must  be  worn. 

^Marked  swelling  may  always  be  expected  as  soon  as  the  patient 


Fig.  206. — Plaster  traction  splint;  a, 
Application  of  adhesive-plaster  extension 
strips;  h,  plaster  bandage  allowing  exit  of 
extension  straps.  Xote  space  left  below 
the  sole  to  allow  for  effective  traction  and 
buckles  to  which  the  upper  extension  is 
attached.     (Scudder.) 


FRACTURES    OE   THE    TIBIA  275 

begins  to  get  about  on  crutches,  a  condition  which  may  alarm  him 
greatly  but  this  and  the  pain  will  gradually  subside  with  increasing 
muscular  and  articular  activity. 


Fig.  207. — Perfect  coaptation  secured  by  plating,  but  in  this  case  same  results  would 
probably  have  followed  non-operative  treatment  since  the  fracture  was  not  oblique.  If 
the  fracture  requires  plating  at  all  a  longer  and  stronger  plate  than  is  shown  should  be  used. 

The  muscular  atrophy  and  joint  stiffness  are  not  the  least  to  be 

considered  of  the  complications  of  convalesence  and  it  is  to  be 

remembered  they  are  aggravated  by  prolonged  immobilization.* 

*For  remarks  on  plating  see  Fig.  207;  fracture  of  the  anterior  tuberosity  of 
the  tibia,  Fig.  208;  and  page  207. 


276  FRACTURES    OF    THE    EXTREAHTIES 

Pott's  Fracture. — Fracture  of  the  fibula  with  eversion  and  ab- 
duction of  the  ankle  has  a  character  of  its  own.  As  Stimson  remarks, 
the  diagnosis  can  usually  be  made  at  a  glance  (Fig.  210).  Three 
points  of  tenderness  on  pressure  are  constant  and  characteristic:  one 


Fig.  208. — Fracture  of  the  tubercle  or  anterior  tuberosity  of  the  tibia,  point  of  insertion 
of  the  patellar  tendon  is  not  rare  and  usually  due  to  striking  the  knee  while  strongly  flexed. 

There  may  be  considerable  displacement  and  disability  and  in  some  cases  it  may  be 
necessary  to  wire  the  fragment.  Usually  fixation  of  the  extended  leg  for  three  weeks  is 
sufficient  for  a  union. 

in  the  groove  between  the  tibia  and  external  malleolus;  another  at 
the  base  of  the  internal  malleolus;  the  third  over  the  outer  aspect  of 
the  fibula,  marking  the  point  of  fracture.  Marked  ecchymosis 
appears  beneath  the  external  malleolus  and  sometimes  beneath  the 
internal  (Fig.  211).     Immediate  reduction  should  be  the  rule. 


FRACTURE    OF   THE   FIBULA 


277 


Reduction. — Grasp  the  foot  in  one  hand,  the  heel  in  the  other,  and 
while  the  leg  is  steadied  by  the  assistant,  draw  the  foot  forward  and 


Fig.  209. — Fracture  of  the  fibula  in  iia  lowc-r  ihirJ  or  nt-ar  the  malleolus  may  be  unsus- 
pected and  the  symptoms  be  attributed  to  a  sprain  of  the  ankle.  But  swelling  and  tenderness 
above  the  ankle  with  much  pain  on  walking  will  give  rise  to  the  suspicion  of  fracture 
which  the  X-ray  will  confirm. 

The  patient  must  keep  off  his  feet  for  three  weeks  with  the  leg  lightly  splinted  with  the 
foot  in  good  position,  massage.  The  nearer  the  fracture  is  to  the  joint  the  greater  the 
tendency  to  flat  foot. 


inward.  If  this  does  not  entirely  succeed,  the  fragments  may  be 
pressed  into  place.  With  the  foot  at  a  right  angle  and  the  malleoh 
in   their   normal   relations,  the   dressing   is   applied.     This   dress- 


278 


FR.A.CTURES    OF    THE    EXTREMITIES 


Fig.  210. — Pott's  fracture. 


ing,  to  quote  Stimson  further,  is  preferably  a  posterior  and  lateral 

plaster  splint  although  the 
plaster  cast  may  be  used. 

The  plaster  splint  may  be 
made  from  twelve  to  thir- 
teen layers,  cut  from  a 
4-inch  plaster  roller.  The 
posterior  splint  should  be 
long  enough  to  extend  from 
the  toes  along  the  sole  and 
up  the  calf  nearly  to  the 
knee  (Fig.  212).  The  lateral 
one  should  begin  just  in 
front  of  the  external  malle- 
olus, pass  over  the  dorsum  of  the  foot  to  the  inner  side,  under  the 

whole  and  up  along  the  outer  side  of 

the  leg  to  the  same  height  as  the  poste- 
rior (Fig.  213).     They  are  snugly  molded 

and  bound  to  the  limb  while  still  wet, 

with  a  roller  bandage. 

In  the  meantime,  till  the  plaster  sets, 

the  reduction  must  be  maintained. 
Dupuytren's  spHnt  is  often  of  great 

service  in  this  fracture,  especially  as  a 

temporary  dressing.     It  consists  of  in- 
ternal lateral  splint,  well  padded  over 

the    ankle    and    which    extends    from 

above   the   knee  and  projects  beyond 

the    foot.     It   is   held   in   place   by   a 

bandage    at    the   knee  and  above   the 

ankle.    The  foot  is  then  abducted,  flexed 

to  a  right  angle  to  the  leg  and  secured 

to  the  splint  by  a  third  bandage  (Fig. 
214). 
These   fractures    are  always  serious 

from  a  functional  point  of  view  and  the 

after  treatment  is  of  the  utmost  importance. 


Fig.  211. — Pott's  fracture.     Note 
fracture  of  internal  malleolus. 


PUTT  S    fKACTURE 


279 


Fig.   212. — Posterior  splint  applied. 
(Stimson.) 


Fig.  213. — Lateral  splint 
applied.     (Stimson.) 


Fig.  214. — Dupuytren's  splint.     Temporary  dressing  for  Pott's  fracture. 


2  8o 


FRACTURES    OF    THE    EXTREMITIES 


Flat  foot  is  likely  to  occur  from  too  early  use  not  less  than  from 
imperfect  reduction. 

Six  to  twelve  weeks  is  required  for  a  repair  sufficient  to  bear  the 
patient's  weight. 

FRACTURE  OF  THE  FOOT 

Fracture  of  the  astragalus  may  occur  independent  of  injury  to 
the  other  bones  and  may  occur  with  or  without  displacement  of 


Fig.  215. — Fracture  o    os  calcis;  result  of  fall,  landing  upon  the  feet. 

the  fragments.  The  swelling  of  the  ankle,  the  pain  on  pressure 
on  the  heel  suggest  the  nature  of  the  injury  but  only  the  X-ray 
can  make  a  definite  diagnosis.     Fracture  of  the  body  usually  calls 


FRACTURES    OF   THE   FOOT 


281 


for  enucleation  because  of  the  non-union  which  is  the  usual  event 
and  is  accompanied  by  a  persistent  but  low  grade  of  arthritis. 
Fracture  of  the  neck  is  more  favorable  under  proper  treatment 
which  consists  in  prolonged  immobilization  in  forced  extension.  Six 
weeks  at  least  must  elapse  before  any  weight  is  borne.  It  is  essential 
that  this  condition  be  not  mistaken  for  a  sprain. 

Fracture  with  displacement  may  give  rise  to  various  deformities 
but  the  most  common  is  lateral  dislocation  of  the  foot.     Its  inner 


Fig.  216. — Fracture  of  phalanges  of  the  foot. 


border  is  markedly  curved,  the  outer  malleolus  projecting  and  the 
dislocated  fragment  palpated  in  front  or  behind  the  joint.  Under 
such  circumstances  an  open  operation  is  indicated  with  the  purpose 
of  replacing  the  fragments  or  performing  a  partial  or  complete 
astragalectomy,  and  in  this  latter  the  operation  will  usually  terminate. 
Fracture  of  the  os  calcis,  due  to  falls,  the  patient  landing  on  his 
feet,  produces  an  impaction  which  flattens  and  widens  the  heel 
and  lowers  the  malleoli.     The  pain,  swelling  and  disability  are  con- 


.282  FRACTURES    OF    THE    EXTREAQTIES 

stant  but  an  accurate  diagnosis  can  be  made  only  by  the  X-ray 
(Fig  215). 

The  prognosis  depends  in  some  degree  upon  the  line  of  fracture, 
but  on  the  whole  the  outlook  is  bad. 

Prolonged  rest,  massage,  hot  baths,  etc.,  may  eventually  overcome 
a  large  part  of  the  lameness  but  under  certain  circumstances  an 
operation  with  readjustment  and  suture  of  the  fragments  will  produce 
an  excellent  result. 

Fractures  of  the  bones  of  the  toes  require  much  longer  immobiliza- 
tion than  corresponding  fractures  in  the  hand  (Fig.  216).  The  de- 
formity and  callus  formation  may  produce  points  of  pressure  that 
become  serious  impediments.  These  fractures  should  therefore  be 
treated  with  circumspection. 


CHAPTER   XV 

COMPOUND  FRACTURES 

It  were  perhaps  better  at  once  to  proscribe  the  ancient  term  ''Com- 
pound" as  applied  to  open  fractures;  but  after  all  it  conveys  an  idea 
of  duplication  of  traumatisms.  And  it  is  only  within  a  recent  period 
that  a  compound  fracture  did  not  mean  also  an  infected  one. 

Thanks  to  antisepsis,  most  open  fractures  at  this  time,  progress 
toward  repair  as  rapidly  as  the  closed. 

But  these  open  fractures  require  a  particular  care,  and  without 
appropriate  treatment,  are  as  prone  to  give  rise  to  dangerous  compli- 
cations as  in  former  times.  The  outcome  in  a  given  case  depends 
largely  on  the  first  treatment.  The  indications  are  various,  deter- 
mined by  the  amount  of  fragmentation,  the  degree  of  destruction  of 
the  soft  parts,  the  injury  to  the  blood  vessels  and,  based  upon  these 
factors,  several  clinical  groups  may  be  distinguished. 

I.  Compound  Fracture,  Small  Skin  Wound;  no  Injury  to  Blood 
Vessels. — The  first  point  to  be  determined  is  whether  the  skin  lesion 
communicates  with  the  bone  lesion.  Often  a  fragment  of  bone  pro- 
jects; in  other  cases  an  undue  amount  of  bleeding  suggests  perforation 
of  the  soft  parts.  In  any  event,  the  wound  must  not  be  probed  and  if 
there  is  doubt  the  fracture  must  be  regarded  as  open.  The  treat- 
ment is  simple  and  exact.  Cover  the  wound  and  proceed  to  paint  the 
field  with  iodine.  Wait  five  to  ten  minutes  for  the  solution  to  pene- 
trate the  skin  and  then  proceed  to  sterilize  the  wound  itself,  injecting 
it  with  iodine  from  a  medicine  dropper  and  subsequently,  if  the  size 
of  the  opening  permits,  wipe  it  out  with  a  gauze  swab  saturated  with 
iodine.  A  sterile  dressing  is  applied  and  from  this  point  the  fracture 
is  treated  as  if  it  were  closed,  and  appropriate  splinting  employed. 

II.  TJie  Wound  is  Large,  the  Bone  Exposed  and  Soiled. — In  this 
case,  under  general  anesthesia,  the  wound  must  be  freely  enlarged 
and  the  ends  of  the  bone,  as  well  as  the  soft  parts,  painted  with 
iodine.     If  every  angle  and  corner  of  the  wound  and  the  bone  is 

283 


284  COMPOUND   FRACTURES 

particularly  and  carefully  cleaned  with  the  solution,  infection  is 
only  remotely  probably.  The  bones  are  to  be  adjusted,  fixed  with  a 
bone  clamp  if  the  apposition  is  difficult  to  maintain,  the  muscle  and 
fascia  sutured  without  drainage,  and  the  skin  wound  with  drainage. 
Some  form  of  splint  is  applied  which  will  readily  permit  inspection 
of  the  wound,  and  the  bone  clamps  removed.  The  dressing  must  be 
ample. 

III.  Large  Wound,  much  Crushing  of  the  Soft  Parts,  much  Frag- 
mentation.— The  principle  of  antisepsis  is  the  same  as  in  the 
previous  case,  but  the  disposition  of  the  fragments  presents  a  new 
problem.  It  is  best,  we  think,  to  proceed  in  this  wise:  Sterilize 
the  skin  and  other  soft  parts  wdth  iodine,  enlarge  the  wound,  ster- 
ilize the  bone  fragments  with  the  iodine  and  then  douche  the  cavity 
with  hot  normal  solution  until  all  the  clots  and  debris  are  removed 
and  all  the  oozing  checked.  Next  proceed  to  restore  the  outline  of 
the  bone,  replacing  the  fragments  as  nearly  as  possible  in  their  nor- 
mal relations,  suturing  them  to  the  main  body  of  bone  with  chromic 
gut  or  securing  them  by  bands  of  the  same  material,  encircling  the 
shaft. 

These  cases  are  better  drained  for  the  first  two  or  three  days  after 
which,  if  there  are  no  signs  of  infection,  the  drain  should  be  left  off. 

Formerly,  it  was  the  practice  to  discard  the  fragments  of  bone.  If 
infection  can  be  avoided  or  reduced  to  a  minimum  the  fragments 
will  live  and  add  greatly  in  restoring  form  and  function.  Even  if  the 
periosteum  is  denuded,  the  fragments,  though  destined  to  be  ab- 
sorbed, will  serve  as  scaffolding  for  the  new  bone  cells,  greatly 
promoting  osteogenesis. 

IV.  Extensive  Fragmentation,  Extensive  Destruction  of  the  Soft 
Parts,  Obliteration  of  the  Principal  Arteries. — In  such  cases  it  is  the 
part  of  wisdom  to  amputate.  Occasionally  the  limb  may  be  saved 
but  the  attempt  exposes  to  an  infection  that  may  cost  the  patient 
his  life.  The  recovery  of  a  useful  limb  in  these  circumstances  is 
so  rare  as  scarcely  to  justify  assuming  the  septic  risk. 

V.  Infected  Compound  Fracture. — If  infection  occurs  by  reason  of 
no  treatment,  or  unsuccessful  treatment,  the  temperature  rises, 
the  limb  swells,  the  pain  augments — in  short,  the  local  and  consti- 
tutional signs  and  symptoms  of  infection  supervene.     These  must  be 


GAS  BACILLUS   INFECTION  285 

walclicd  for  in  every  case,  and  the  patient  kept  under  close  sur- 
veillance. 

Once  infection  manifests  itself,  the  wound  must  be  opened,  re- 
moving the  sutures  if  necessary,  and  the  wound  irrigated  with  per- 
oxide of  hydrogen.  Oftentimes  it  is  only  the  skin  wound  which  is 
infected  and  the  deeper  levels  of  the  wound  should  not  be  disturbed 
until  it  is  certain  they  have  been  invaded. 

Even  if  the  bone  itself  is  involved  an  excellent  result  may  still  be 
obtained,  provided  the  splinting  is  efficient,  the  drainage  ample,  and 
the  general  treatment  sensible. 

So  much  cannot  be  said  if  the  infection  is  from  the  gas  bacillus. 
This  extremely  dangerous  form  of  sepsis  develops  usually  the 
second  or  third  day  and  is  preceded  by  pain  in  the  wound,  out  of  all 
proportion  to  its  apparent  seriousness.  The  wound  looks  red  and 
angry  and  exudes  a  bloody,  fetid  serum;  presently  the  limb  begins  to 
swell,  the  skin  is  crepitant,  and  blebs  form.  These  manifestations 
extend  with  the  greatest  rapidity,  accompanied  by  grave  constitu- 
tional manifestations  which  end  in  death  in  twenty-four  to  seventy- 
two  hours.  The  diagnosis  must  be  made  at  the  very  beginning  of 
the  process  if  the  treatment  is  to  be  of  any  use.  Severe  pain,  an 
unexpected  rise  in  temperature  the  first  days  should  put  one  on  his 
guard  and  at  the  first  appearance  of  crepitation  in  the  skin  an  am- 
putation well  above  the  infected  site  must  be  performed.  If  the 
case  is  untreated  or  if  the  treatment  is  ineffective  the  progress  of 
the  disease  is  extremely  rapid  although  there  is  nothing  else  charac- 
teristic of  this  form  of  toxemia. 

A  workman  was  brought  to  the  City  Hospital  with  a  compound 
fracture  of  the  lower  end  of  the  radius.  The  injury  was  twenty-four 
hours  old.  The  wound  was  cleansed,  the  fracture  splinted;  but  the 
patient  suffered  extremely,  out  of  all  proportion  to  his  injury;  his 
temperature  began  to  rise  and  at  the  end  of  the  second  day  it  was 
clear  that  a  gas  bacillus  infection  was  under  way.  He  understood 
no  English,  but  an  interpreter  explained  that  he  must  loose  his  arm  or 
his  life.  He  chose  the  latter.  At  the  end  of  the  third  day  the  arm 
and  shoulder  were  immensely  swollen,  the  skin  crepitant  and  cov- 
ered with  blebs  and  a  few  hours  later  he  died  in  great  agony. 

An  almost  identical  injury  occurred  in  a  fall  from  a  cherry  tree. 


•86 


COMPOUND   FRACTURES 


The  signs  of  the  infection  promptly  developed,  the  end  of  the  bone 
having  been  covered  with  soil.  The  patient,  a  middle  aged  woman, 
consented  readily  to  amputation  at  the  shoulder.  The  flaps  were 
left  open  and  packed  with  gauze  saturated  with  peroxide.  She  made 
an  uninterrupted  recovery. 

In  the  young  and  healthy  patient  in  the  very  early  stages  of  the 
disease  a  more  conservative  treatment  may  succeed.  Multiple  deep 
incisions,  packing  the  w^ounds  with  peroxide  gauze  or  injecting  the 


Fig.   217. — Compound  fracture  of  tibia.      (Moullin.) 

soft  parts  above  the  level  of  infection  with  the  peroxide.  Finally  the 
danger  of  tetanus  is  to  be  emphasized  and  in  every  case  of  compound 
fracture  which  has  not  been  treated  from  the  first  in  the  manner 
described,  a  prophylactic  dose  of  antitetanic  serum  should  be 
administered. 


COMPOUND    FRACTURE    OF    THE    TIBIA 

These  are  by  far  the  most  frequent  and  require  a  special  attention 
both  that  infection  may  be  avoided  and  that  the  limb's  functions  may 
be  preserved.  (Fig.  217,  218)  The  tibia  is  so  near  the  surface  and 
the  line  of  fracture  is  so  likely  to  be  oblique,  producing  sharp  points 
of  bone,  and  displacement  is  so  common;  these  facts  explain  the 
frequency  of  open  fractures  of  the  tibia. 

The  antisepsis  in  these  cases  presents  no  special  feature;  the  chief 
problem  is  in  maintaining  coaptation.  If  the  fracture  is  oblique  or 
the  bone  much  splintered,  it  is  best  to  proceed  in  this  manner;  after 
cleansing  both  outside  and  inside  the  wound  with  iodine,  enlarge 


COMPOUND   FRACTURE    OF   THE    Til}  I A 


287 


the  wound  freely,  clean  out  all  the  clots  and  debris.  The  amount  of 
injury  to  the  soft  parts  is  often  surprising.  Expose  the  bone  suf- 
ficiently to  secure  an  accurate  coaptation  of  all  the  fragments.  Now 
apply  a  bone  clamp  in  order  to  force  the  bones  into  intimate  contact 
and  to  hold  them  in  that  position  until  the  dressing  is  applied. 

Before  beginning  the  operation,  have  fifteen  layers  of  crinoline  cut 
from  a  pattern  for  a  posterior  splint  and  saturated  with  dry  plaster  of 


Fig.  218. — Compound  comminuted  fracture  of  tibia  and  fibula. 


Paris.  The  dressing  having  been  applied  to  the  wound  in  such  manner 
as  not  to  interfere  with  the  removal  of  the  clamp,  the  posterior  splint 
is  soaked  and  then  molded  to  the  leg  and  fixed  with  a  few  layers  of 
roller  plaster.  In  the  course  of  fifteen  minutes  the  plaster  is  hard- 
ened and  the  clamp  may  be  loosened  and  removed.  Interrupted 
sutures  placed  but  not  tied  can  now  be  tightened  and  an  additional 
cover  of  gauze  applied  to  the  wound. 


288  COMPOUND  FRACTURES 

Usually  there  is  considerable  oozing  for  the  first  few  hours,  necessi- 
tating frequent  change  of  dressings,  the  best  form  of  which  is  gauze 
saturated  with  alcohol,  this  covered  with  absorbent  cotton  and  the 
whole  firmly  bandaged.  With  a  properly  applied  and  effective  splint 
the  limb  can  be  handled  and  the  dressings  changed  with  but  little 
difficulty.  Special  care  must  be  taken  to  prevent  soiling  of  the 
plaster  splint  since  changing  this  short  of  two  wrecks  may  result  in 
recurrence  of  some  displacement.  Mild  infection  may  occur  but  is 
easily  managed  on  general  principles.  Our  results  by  this  method 
have  been  excellent. 


COMPOUND    FRACTURE    .\BOUT    THE    ANKLE    AND    FOOT 

Fractures  of  this  variety  are  frequent;  always  serious;  and  the 
prognosis  more  or  less  uncertain,  depending  upon  the  degree  of  in- 
fection and  destruction  of  the  soft  parts. 

Suppose  a  fracture  of  the  inner  malleolus:  the  soft  parts  are  widely 
separated,  the  joint  cavity  exposed,  the  astragalus  dislocated.  Such 
an  injury  must  be  as  conservatively  treated  as  an  abdominal  wound. 
Under  no  circumstances  must  the  wound  be  explored  with  unclean 
fingers  or  without  careful  cleansing  of  the  field.  Only  after  all  the 
preparations  for  definite  treatment  are  made  is  the  wound  to  be  ex- 
amined. If  transportation  is  necessary,  a  temporary  splint  is  pro- 
vided, but  at  least  do  not  cover  the  wound  with  a  dirty  handkerchief. 
If  there  is  much  hemorrhage,  circular  constriction  of  the  leg  about 
the  knee  will  temporarily  suffice. 

The  first  dressing  will  determine  the  future  of  the  limb,  perhaps 
even  the  life  or  death  of  the  wounded.  The  whole  foot  and  the  lower 
half  of  the  leg  are  most  carefully  disinfected  and  the  fracture  and 
joint  cavity  swabbed  with  iodine,  enlarging  the  wound  if  necessary 
to  expose  every  nook  and  corner  in  order  to  wdpe  out  foreign  bodies, 
splinters  of  bone  and  clots  of  blood.  In  this  case,  merely  chosen  for 
example,  the  destruction  of  tissue  is  usually  slight.  After  the 
cleansing,  replace  the  parts,  leave  one  or  two  drains  in  the  partly 
sutured  wound,  bandage  amply  and  place  the  limb  at  rest. 

The  situation  is  less  simple  where  there  is  much  destruction  of 
tissue,  as  in  the  case  where  the  ankle  is  crushed. 


COMPOUND  FRACTURE  OF  ANKLE  289 

Begin  with  hot  irrigations  of  normal  salt  solution.  Do  not  fear  to 
enlarge  the  wound  freely.  It  is  of  great  importance  that  one  be  able 
to  determine  definitely  the  conditions  in  the  wound  and  to  see  what 
he  is  doing. 

You  may  find  large  fragments  deformed  and  overlapping.  Try 
to  replace  them  and  often  you  will  be  thus  enabled  to  restore  the 
contour  of  the  joint.  To  retain  these  fragments,  wiring  or  nailing 
the  fragments  will  often  be  an  almost  indispensable  aid. 

Another  case:  The  epiphyses  are  reduced  to  fragments  of  various 
sizes  and  forms.  In  irrigating,  they  flow  away  with  the  solution,  so 
loosened  are  they.     The  rest  hang  by  a  mere  shred. 

Reposition  is  here  useless.  The  wreck  is  too  great.  You  must 
proceed  to  do  an  atypical  resection.  Do  your  best  to  spare  the  mal- 
leoli or  at  least  two  processes  which  wdll  serve  to  prevent  lateral  dis- 
location when  the  joint  is  healed. 

After  this  operation  insert  two  drainage-tubes,  one  on  either  side; 
and  if  there  is  considerable  oozing,  add  an  aseptic  tamponade. 

The  prognosis  is  worse  if  infection  has  developed  and  there  is  fever, 
redness,  and  swelling  in  the  limb.  Amputation  will  be  the  measure 
of  last  resort  and  yet  do  not  amputate  until  free  opening  has  again 
been  tried.  Irrigate  with  peroxide.  The  removal  of  dead  bone, 
etc.,  is  followed  by  deep  drainage  but  this  must  be  done  without 
delay.  It  is  not  union,  or  consolidation,  or  function  of  the  limb 
which  is  the  chief  concern.  It  is  infection  against  which  all  the  forces 
of  antisepsis  are  marshalled. 

Osteomyelitis  is  the  contingency  feared.  In  such  a  case,  do  not 
employ  a  typical  amputation  or  resection,  but  an  atypical  one,  re- 
moving only  such  tissues  as  must  be  removed,  and  later  when  the  in- 
fection has  disappeared,  the  necessary  operations  may  be  done.  For 
additional  remarks  on  treatment  of  compound  fractures  see  Gunshot 
Fractures  (page  155). 


19 


CHAPTER  XVI 


FRACTURE  OF  THE  CLAVICLE,  SCAPULA,  RIBS, 
SPINE,  PELVIS 

Fractures  of  the  clavicle  formerly  occurred  more  frequently  than 
any,  other,  but  are  not  now  so  frequent.  One-half  of  the  cases  are 
in  children.  The  break  very  much  more  often  occurs  in  the  middle 
third,  occasionally  in  the  outer  third,  but  rarely  in  the  inner  third. 
In  the  middle  third,  the  inner  fragment  overrides  the  outer,  the  re- 


FiG.  219. — Fracture  of  clavicle.     Inner  fragment     Fig.  220. — Velpeau's     bandage     for 
lifted  upward  by  sterno-mastoid.     {Moullin.)  fractured  clavicle.     {Stewart.) 

suit  of  the  action  of  the  sterno-cleido-mastoid  and  the  muscles  that 
pass  from  the  thorax  to  the  humerus,  and  the  weight  of  the  shoulder 
(Fig.  219). 

The  patient  leans  his  head  toward  the  injured  side  and  supports 
the  elbow,  the  position  of  greatest  comfort.  The  nature  of  the 
accident,  the  pain,  deformity,  crepitus,  and  mobility  determine  the 
diagnosis. 

Reduction. — Seat  the  patient  on  a  low  stool;  direct  the  assistant 
to  stand  behind  and  to  grasp  the  patient's  shoulders,  steadying  the 
sound  one  with  one  hand  and  lifting  the  injured  one  upward^  back- 

290 


FRACTURE    OF   THE   CLAVICLE 


291 


ward,  and  outward.  At  the  same  time  the  operator  stands  in  front, 
helping  move  the  shoulder;  and,  by  pressure  and  manipulation  of 
the  clavicle  between  finger  and  thumb,  molds  the  broken  ends  into 
place. 

The  reduction  is  complete  when  the  injured  shoulder  is  as  long 
as  the  sound  one,  measuring  each  from  the  sterno-clavicular  joint 
to  the  tip  of  the  acromion,  landmarks  which  can  always  be  defined. 
Feel  along  the  injured  clavicle  for  any  irregularities.  Apply  the 
dressing,     (i)  If  the  patient  is  to  be  kept  in  bed  for  other  reasons 


Fig.  221. — Sayre's  dressing.     Fig.   222. — Sayre's  dressing  corn- 
First  stage.     (Moullin.)         pleted.  Posterior  view.    (Moullin.) 


Fig.  223. — Anterior 
view.     (Moullin.) 


than  the  clavicular  fracture,  it  will  be  sufficient  to  keep  him  on  his 
back  with  a  small  pillow  between  his  shoulders  and  with  the  hand 
lifted  to  the  chest. 

(2)  Any  bandage  or  dressing  which  draws  the  shoulder  upward, 
outward,  and  backward,  and  holds  it  in  that  position  will  serve.  Of 
the  dressings,  a  number  are  especially  recommended,  among  them, 
the  Velpeau  type  of  bandage  (Fig.  220).  They  need  to  be  applied 
for  three  or  four  weeks. 

In  ordinary  practice,  the  Sayre's  dressing  is  excellent.  The  es- 
sentials are  two  adhesive  strips  3  inches  wide  and  long  enough 
to  go  once  and  a  half  about  the  body,  absorbent  cotton,  roller  band- 


292 


FRACTURES    OF    THE    CLAVICLE,    SCAPULA,    RIBS,    ETC. 


ages.  Begin  by  fixing  the  end  of  one  adhesive  strip  loosely  about  the 
injured  arm  iust  below  the  armpit.  The  loose  end  carried  around 
the  body  will  pass  over  the  lower  ends  of  the  scapulae.  Before  com- 
pleting the  turn  about  the  body,  place  layers  of  cotton  wherever  the 
cutaneous  surfaces  are  to  be  in  contact.  The  turn  of  the  adhesive 
strip  about  the  body  is  completed.  This  holds  the  shoulder  in  the 
backward  and  outward  position  (Fig.  224).  The  hand  is  drawn 
across  the  chest  toward  the  sound  shoulder  and  the  second  adhesive 


Fig. 


4.  —  Mayor's  sling.      First  stage.      yLejars.) 


Strip  is  applied.  Fix  one  end  over  the  sound  shoulder  and  pass  it 
across  the  back  to  the  elbow  (Fig.  222).  It  covers  the  point  of  the 
elbow  and  follows  the  arm  across  the  chest  to  the  starting-point 
(Fig.  223).  It  is  designed  to  lift  the  shoulder  upward.  A  few  turns 
of  roller  bandage  around  the  chest  lend  additional  support  and  com- 
plete the  dressing. 

Romer  describes  a  method  of  dressing  with  adhesive  strips  which 
does  not  require  the  arm  to  be  fixed  to  the  side  (Lancet,  London, 


THE    MAYOR    SLING 


293 


March  31,  1909).  Three  strips  of  Z.  O.  plaster,  each  an  inch  and 
a  half  in  width,  should  be  applied  from  a  point  immediately  above 
the  nipple,  passing  over  the  clavicle  to  a  point  below  the  angle  of  the 
scapula.  The  middle  strip  should  cover  the  site  of  the  fracture  and 
should  be  first  applied,  the  lateral  ones  overlapping  it.  The  strips 
should  be  firmly  applied  while  the  fragments  are  kept  in  apposition. 


Fig.  22s. — Mayor's  sling.  Second  stage. 
The  bandage  is  molded  snugly  to  the  arm. 
(Lejars.) 


Fig.   226. — Mayor's  sling  completed. 
iLejars.) 


The  scapula  may  be  steadied  by  a  strip  crossing  its  lower  angle  lat- 
erally.    The  arm  is  to  be  carried  in  a  sling. 

Mayor's  sling  serves  an  excellent  purpose  here  as  well  as  in  certain 
injuries  to  the  arm.     It  is  applied  in  this  manner: 

Take  a  square  of  strong,  unbleached  muslin,  or  similar  material, 
large  enough  to  reach  easily  about  the  body;  fold  it  into  a  triangle. 


294 


FRACTURES    OF   THE   CLAVICLE,    SCAPULA,    RIBS,    ETC. 


The  elbow  having  been  flexed  to  an  acute  angle  and  the  hand  carried 
toward  the  sound  shoulder,  the  bandage  is  carried  across  the  flexed 
arm  and  around  the  chest,  its  upper  level  being  just  below  the  level 
of  the  axilla  (Fig.  224).  The  two  points  are  fastened  behind  with 
a  safety-pin  or  tied. 

Now  turn  the  third  point  of  the  triangle  upward  between  the 
flexed  arm  and  the  body,  and  carry  it  up  over  the  shoulder  of  the 
injured  side  (Fig.  225).  Mold  the  bandage  well,  so  that  it  fits  and 
supports  the  forearm  snugly.  The  dressing  is  completed  by  bands 
crossing  over  the  shoulders  and  connecting  the  anterior  and  posterior 
parts  of  the  bandage  after  the  manner  of  suspenders  (Fig.  226). 


FRACTURE  OF  THE  SCAPULA 

These  fractures  are  comparatively  rare,  about  i  per  cent,  of  all 
fractures. 

The  body,  the  spine,  the  acromion  process,  the  coracoid  process 

may  be  involved  and  the  fracture 
is  usually  due  to  direct  violence. 

The  X-ray  will  often  be  neces- 
sary to  locate  the  lesion  definitely 
although  the  pain,  tenderness,  and 
perhaps  crepitation  will  determine 
the  presence  of  some  kind  of  frac- 
ture. In  the  case  of  the  acromion 
process  the  functions  of  the  deltoid 
are  disturbed;  in  the  case  of  the 
coracoid,  the  biceps  and  pectoralis 
minor.  Respiration  may  be  pain- 
ful by  reason  of  the  pull  on  the 
latter  muscle. 

The  action  of  these  muscles 
must  be  considered  also  in  instituting  treatment.  It  is  sufficient 
usually  to  fit  the  arm  in  a  sling  and  immobilize  the  scapula  by  adhe- 
sive strapping. 

Fracture  of  the  neck  (Fig.  227)  is  of  importance  because  it  may  be 
mistaken  for  fracture  of  the  surgical  neck  of  the  humerus  but  in  such 


Fig.  227. — Fracture  of  the  neck  of  the 
scapula. 


FRy\CiUkE    OF    THE    SCAPULA  295 

a  case  the  head  can  be  felt  to  rotate,  which  it  would  not  do  in  disloca- 
tion. The  deformity  disappears  on  lifting  the  arm  forcibly  upward 
with  the  elbow  flexed,  which  does  not  happen  in  a  case  of  fracture  of 
the  humerus;  the  arm  hangs  vertically  at  the  side  and  is  mobile. 
There  is  no  notching  of  the  deltoid. 

In  the  case  of  fracture  of  the  surgical  neck  of  the  humerus  with 
overriding,  the  arm  is  shortened.  In  case  of  fracture  of  the  scapular 
neck,  the  arm  is  lengthened. 

Generally  speaking,  the  diagnosis  of  any  fracture  of  the  scapula  is 
to  be  made  from  crepitus,  abnormal  mobility,  local  tenderness,  and 
more  or  less  complete  loss  of  certain  functions.  Begin  the  examina- 
tion by  inspection  and  measurement.  Note  any  loss  of  contour; 
any  lengthening  or  shortening  of  arm.  To  elicit  crepitus,  apply  one 
hand  to  the  body  of  scapula  and  with  the  other  make  traction  on  the 
arm.  In  thin  subjects  the  lower  end  of  the  scapula  may  be  readily 
grasped. 

Treatment. — The  flexed  elbow  should  be  well  supported  by  a  sling, 
and  the  arm  fixed  at  the  side.  Massage  wall  relieve  the  pain  and 
hasten  repair.     Mayor's  sling  furnishes  an  excellent  dressing. 

FRACTURE  OF  THE  RIBS 

Fractures  of  the  ribs  occur  most  frequently  between  the  fifth  and 
ninth,  and  are  usually  single  and  without  displacement.  If  the 
violence  is  sufficient  to  break  a  number  of  the  ribs  simultaneously, 
it  may  cave  in  the  chest  wall;  and,  by  perforation  of  the  lung, 
produce  emphysema,  hemoptysis,  pneumothorax.  Pain  and  crepitus 
point  to  the  presence  of  fracture.  Detect  crepitus  by  laying  the 
palm  over  the  site  of  the  pain  or  by  the  stethoscope. 

Slight  displacements  may  be  reduced  by  making  pressure  over 
the  site  of  fracture  during  inspiration,  or  perhaps  by  compressing 
the  chest  from  front  to  back  between  the  two  hands.  Apply  ad- 
hesive strips  2  inches  wide  over  the  injured  side,  beginning  at  the 
scapula,  and  following  the  course  of  the  ribs  around  to  the  sternum. 

Three  or  four  strips  may  be  necessary,  and  they  must  be  applied 
at  the  end  of  expiration. 

The  pain  will  almost  always  be  relieved  by  such  immobilization 


296 


FRACTURES    OF    THE    CLA\aCLE,    SCAPULA,    RIBS,    ETC. 


of  the  chest  wall.     Those  fractures  which  involve  the  viscera  are 
considered  with  injuries  of  the  thorax. 


FRACTURES  OF  THE  VERTEBRA 

Fractures  of  the  vertebra  derive  their  chief  importance  from  the 
accompanying  injury  to  the  spinal  cord  and  are  serious  in  proportion 
to  the  amount  of  injury  to  the  cord,  ligaments,  and  tendons. 

Aside  from  local  pain  and  deformity,  the  symptoms  are  such  as 
arise  from  compression  or  laceration  of  the  cord  and  vary  somewhat, 
depending  on  the  particular  portion  of  the  cord  involved.     Fractures 

of  the  cervical  vertebra  are  at 
once  the  most  common  and 
fatal.  Fractures  in  thelumbo- 
dorsal  region  occur  next  in  fre- 
quency. The  break  which 
usually  involves  the  body  of 
the  vertebra,  but  may  include 
the  lamina  or  transverse  or 
spinous  processes,  is  generally 
due  to  forced  flexion.  Along 
with  the  fracture  the  ligaments 
are  lacerated,  the  muscles  torn, 
the  vertebra  displaced  and  the 
blood  vessels  opened.  There 
may  be  present  paraplegia  and 
disturbances  of  the  functions 
of  bowel  and  bladder;  and  in 
addition  to  these  symptoms 
there  are  certain  others  which  are  common  to  fractures  of  the 
vertebra  wherever  located,  such  as  pain,  tenderness  to  pressure 
and  motion.  Occasionally  one  will  find  deviations  and  angular 
deformities  (Fig.  228). 

The  prognosis  in  a  well-defined  case  is  always  bad,  although  by  no 
means  always  hopeless. 

The  emergency  treatment  is  limited  generally  to  transportation  and 
securing  the  proper  bedding.     The  patient  must  be  handled  with  the 


Fig.  228. — Fracture  of  vertebra.      {MouUin.) 


FRACTURE    OF    THE    SPINE  297 

greatest  care.     Sometimes  the  least  added  pressure  on  the  cord  by 
the  movements  of  the  spine  may  produce  immediate  death. 

The  bed  must  be  uniformly  soft  and  smooth.  A  water  bed  is  ideal. 
If  the  symptoms  of  compression  are  urgent,  it  is  necessary  at  once  to 
make  an  effort  to  reduce  the  fracture  by  simultaneous  traction  and 
pressure.  While  the  assistants  pull  on  the  head  and  feet,  the  doctor 
attempts,  by  pressure,  to  correct  the  deformity.  There  is  some 
danger  of  a  fatal  asphyxia  where  the  fracture  is  high,  in  making  these 
manipulations,  as  the  patient  is  turned  on  his  face  and  the  move- 
ments of  the  diaphragm  may  be  interfered  with.  Laminectomy  is 
not  to  be  considered  when  the  indications  point  to  complete  crushing 
of  the  cord.  In  other  cases  where  the  pressure  symptoms  are 
obvious,  a  laminectomy  should  be  done  with  delay.  (See  Wounds  of 
the  Spine.) 

FRACTURE  OF  THE  PELVIS 

Fracture  of  the  pelvis  may  be  suspected  from  the  character  of  the 
injury,  which  is  usually  a  fall  or  a  crush.  The  diagnosis  is  to  be  con- 
firmed by  external  palpation  of  the  ilium,  pubes,  and  ischium  on  each 
side,  and  by  careful  rectal  and  vaginal  examination.  Disturbance  of 
normal  relations,  tenderness  on  pressure,  crepitation  perhaps,  and 
difficulty  in  walking  indicate  fracture  (Fig.  229). 

The  prominence  of  the  symptoms  will  depend  in  some  degree  upon 
the  amount  of  displacement. 

The  X-ray  of  course  will  be  used  whenever  available. 

The  treatment  in  the  uncomplicated  cases  is  simple.  Usually 
nothing  can  be  accomplished  in  correction  of  the  displacement  and 
simple  rest  in  bed  with  adhesive  strapping  represent  the  elements 
of  relief.  Two  recent  cases  in  the  City  Hospital  treated  in  this 
manner  recovered  in  six  weeks.  It  is  quite  different  if  there  are 
complications. 

If  a  catheter  cannot  be  passed  (and  this  should  always  be  tried), 
it  will  be  necessary  to  do  an  external  urethrotomy  for  the  ruptured 
urethra.  If  the  catheter  finds  the  bladder  empty  and  ruptured,  a 
laparotomy  is  imperative.  If  the  exact  complications  cannot  be 
determined  and  yet  shock,  pain,  and  increasing  abdominal  tension. 


29S 


FRACTURES    OF    THE    CLAVICLE,    SCAPULA,    RIBS,    ETC. 


with  signs  of  sepsis,  point  to  a  lesion  of  bladder  or  rectum,  the  abdo- 
men must  be  opened,  and  the  visceral  injury  found  and  repaired. 

A  woman  was  brought  into  the  City  Hospital  the  victim  of  an 
automobile  collision.  She  was  in  full  shock  and  the  pelvis  was 
plainly  disarranged.  The  shock  improved  a  little  but  the  pulse  re- 
mained rapid  and  weak.  A  catheter  brought  only  a  little  blood 
from  the  bladder.     A  laparotomy  showed  the  bladder  to  be  greatly 


Fig.  229. — Fracture  of  the  pelvis  through  the  obturator  foramen  and  dislocation 
at  the  sacroiliac  joints.      (Moullin.) 


contused,  but  not  torn  and  there  was  much  blood  in  the  cellular  tis- 
sues around;  a  large  hematoma  had  formed  under  the  pelvic  perito- 
neum. Suprapubic  drainage  was  applied  but  the  patient  lived  only 
a  few  hours.  Shock,  the  hemorrhage,  and  beginning  infection  were 
beyond  the  limits  of  her  resistance. 

Following  a  variety  of  traumatisms  there  is  often  a  condition  now 
well  recognized  as  relaxation  of  the  sacroiliac  synchondrosis  which 
simulates  fracture  and  which  may  become  quite  chronic.  It  is  re- 
lieved by  adhesive  strapping. 


CHAPTER   XVII 
FRACTURES  OF  THE  SKULL  AND  FACE 

Fractures  of  the  skull  are  important  practically  only  from  the 
point  of  view  of  their  complications,  which  number  three;  infection, 
hemorrhage,  and  injury  to  the  brain. 

In  a  given  case,  one  or  all  of  these  complications  are  possibilities, 
although  for  the  development  of  each,  certain  combinations  of 
circumstances  are  peculiarly  favorable. 

With  respect  of  these  variations,  fractures  of  the  skull  are  of  two 
classes:  fracture  of  the  base  and  fracture  of  the  vault.  Each  has  its 
special  symptomatology  and  prognosis,  though  the  one  may  merge 
into  the  other  and  the  clinical  picture  be  more  or  less  blurred. 

Either  may  be  fissured,  fragmented,  or  compound,  with  or  with- 
out depression.  In  either  the  immediate  gravity  depends  upon  the 
nature  and  extent  of  the  injury  to  the  brain,  and  fractures  of  the  base  are 
the  more  serious,  merely  because  the  more  important  areas  of  the  brain 
are  there. 

With  regard  to  the  remoter  consequences  also,  fractures  of  the 
base  are  less  favorable;  hemorrhage  and  its  resultant  complications 
are  more  to  be  feared;  and  infection  is  a  more  certain  eventuality 
owing  to  the  communications  opened  up  between  the  cranial  cavity 
on  the  one  side  and  the  ear,  the  nose,  or  the  pharyngeal  region  on  the 
other. 

The  symptoms  in  either  kind  of  fracture  are  such  as  arise  from 
concussion,  compression,  or  laceration  of  the  brain  and  are  general 
or  focal,  that  is  to  say,  emanating  from  certain  cerebral  areas. 

FRACTURES    OF    THE   BASE 

Fractures  of  the  base  of  the  skull  are  more  frequently  indirect,  the 
force  being  transmitted  through  the  spinal  column  from  some  part 
of  the  vault  or  the  ramus  of  the  jaw;  occasionally  direct  by  a  thrust 

299 


300  FRACTURES    OF    THE   SKULL   AND   FACE 

through  the  mouth,  a  blow  on  the  root  of  the  nose,  or  upon  the 
mastoid  process. 

Any  or  all  of  the  fossae  may  be  involved.  Fracture  through  the 
middle  fossa  is  most  frequent,  and  the  most  serious  is  fracture  through 
the  posterior  fossa.  These  fractures  are  usually  linear  because  the 
force  is  indirect  and  because  there  is  only  one  determinable  table 
instead  of  two,  as  in  the  vault. 

These  fractures  are  nearly  always  compound,  which  adds  to  the 
gravity  of  the  prognosis.  The  external  meatus,  the  nasal  cavities 
and  the  naso-pharynx  are  all  prolific  sources  of  meningeal  infection. 

The  diagnosis  is  usually  by  inference,  often  impossible.  There 
are  certain  symptoms  always  suggestive  of  fracture  at  the  base, 
but  not  to  be  relied  upon  exclusively. 

Ecchymosis  in  the  tissues  about  the  orbit,  or  hemorrhage  into  the 
sclerotic,  appearing  first  some  little  time  after  the  injury,  and 
gradually  progressive — 'fracture  through  the  anterior  fossa  suggests 
itself.  Persistent  bleeding  from  the  nose  following  head  injury  must 
be  given  due  consideration.  Bleeding  from  the  external  meatus, 
copious  and  persistent,  suggests  fracture  through  the  middle  fossa. 
Late  ecchymosis  over  the  mastoid  or  into  the  tissues  of  the  back  of 
the  neck  suggests  fracture  through  the  posterior  fossa.  The  dis- 
coloration follow^s  the  posterior  auricular  artery.  How^ever,  these 
hemorrhages  must  not  be  mistaken  for  local  rupture  of  mucous 
membrane  or  other  soft  parts  and  their  absence  does  not  necessarily 
mean  absence  of  fracture. 

The  bleeding,  if  intra-cranial,  may  come  from  rupture  of  the 
middle  meningeal,  or  the  internal  carotid,  or  the  sinuses.  Instead 
of  the  bleeding,  or  accompanying  it,  there  may  be  escape  of  cerebro- 
spinal fluid.  Its  presence  is  pathognomonic  of  fracture  of  the  skull, 
and  it  must  be  distinguished  from  ordinary  serum  and  the  fluid  of 
the  middle  ear  by  these  characteristics:  the  flow  begins  at  once  and 
continues  for  several  hours;  the  quantity  is  considerable,  sometimes 
a  tablespoonful  in  fifteen  to  twenty  minutes;  the  flow  is  temporarily 
increased  by  the  increase  of  intra-cranial  pressure,  sneezing,  cough- 
ing, and  vomiting;  alkaline  in  reaction;  contains  only  a  trace  of 
albumin  and  is  rich  in  sodium  chloride. 

Useful  in  definite  diagnosis  are  the  paralyses  of  the  cranial  nerves. 


FRACTURES    OF   THE    SKULL  3OI 

Recall  their  origin,  course,  and  functions.  The  facial,  optic,  and 
tri-facial  nerves  are  especially  likely  to  be  involved.  For  example, 
the  optic  nerve  will  be  involved  if  there  is  a  fissure  of  the  optic  canal. 
Vision  may  be  lost  totally  and  immediately;  even  though  total  at 
first,  the  blindness  may  gradually  pass  away.  It  will  be  impossible 
for  some  time  to  say  whether  the  recovery  will  be  permanent.  Added 
to  these  nerve  symptoms,  but  not  particularly  helpful  in  the  diagnosis 
of  fracture,  may  be  those  of  concussion,  compression,  or  laceration. 
All  these  conditions  may  exist  with  or  without  fracture. 

The  treatment  has  two  ends  in  view,  the  prevention  of  further  irri- 
tation of  the -brain  and  the  prevention  of  infection. 

Keep  the  patient  absolutely  quiet  in  bed  with  the  head  elevated, 
apply  ice-bags,  and  keep  the  bowels  open. 

Whenever  fracture  of  the  base  is  even  merely  suspected,  care- 
fully wdpe  out  the  external  meatus  and  pack  lightly  with  sterile 
gauze.  Do  not  syringe  the  meatus  or  at  least  only  very  gently,  lest 
infection  be  forced  through  the  fissure. 

Remove  the  gauze  as  often  as  it  becomes  soaked  with  blood,  which 
may  be  at  frequent  intervals  for  several  days.  Spray  the  nose  and 
throat  with  peroxide  of  hydrogen  or  a  similar  mild  antiseptic.  These 
regions  cannot  be  sterilized,  but  bacterial  activity  may  be  mini- 
mized. Do  not  pack  the  nares  except  for  persistent  nasal  hemor- 
rhage, as  the  packing  irritates  the  mucosa  and  unduly  stimulates 
secretion,  and  this  is  undesirable.  x\gain,  such  packing  may  excite 
a  sneeze  which  by  its  explosive  effect  may  carry  infection  through 
the  fissure  to  the  meninges.  If  packing  is  deemed  necessary,  pack 
with  sterile  gauze  saturated  with  sterile  vaseline.  In  the  great 
majority  of  cases,  active  intervention  is  quite  out  of  the  question  either 
for  the  relief  of  infection  or  for  hemorrhage.  But  this  is  true  merely 
because  the  technic  is  not  definitely  worked  out.  The  principle  of 
drainage  for  infection  and  removal  of  compressing  clots  applies  with 
as  much  force  here  as  in  fractures  of  the  vault  (see  Craniectomy). 

FRACTURES    OF    THE  VAULT 

Fractures  of  the  vault  of  the  skull  may  be  fissured,  comminuted 
or  compound,  any  one  of  which  may  be  complicated  by  concussion, 
compression,  contusion,  or  intra-cranial  hemorrhage.     The  symp- 


.^02 


FRACTURES  OF  THE  SKULL  AND  FACE 


# 


toms  belong  to  the  brain  complications  rather  than  to  the  fracture 
itself. 

Simple,  fissured  fracture  without  depression  is  practically  im- 
possible of  diagnosis.  The  diagnosis  is  easier  if  depression  is  pres- 
ent, and  yet  certain  injuries  to  the  scalp  simulate  fracture  with  de- 
pression. A  blow  crushes  the  soft  tissues  and  around  the  crushed 
area  marked  swelling  ensues.  The  sensation  to  the  examining  finger 
is  that  of  a  depression  of  the  bone.     Do  not  be  misled. 

Comminuted  fracture  of  the 
skull  even  without  depression 
is  generally  diagnosed,  and  yet 
a  hematoma  may  mask  the 
fragmentation.  Be  on  your 
guard  in  that  matter. 

The  inner  table  is  always 
more  injured  than  the  outer 
(Figs.  230,  231). 

The  prognosis  is  good  and  the 
treatment  simple  in  fissured 
fracture  without  depression  and 
without  symptoms  indicating 
compression. 

Put  the  patient  to  bed,  keep 

Fig.   230.— Fracture    of    outer    table    from     ^J^g  bowels  OpCU,  limit  the  diet, 
impact  of  a  hammer.     (MouUin.)  .11  j  t- 

and  await  developments,  un- 
interrupted recovery  usually  follows,  yet  the  exceptions  to  this  rule 
are  not  infrequent  and  one  must  be  on  his  guard  for  intra-cranial 
hemorrhage.  Or  later,  there  may  develop  symptoms  which  are 
explainable  only  on  the  h}'pothesis  of  contusion  of  the  brain. 

If  at  any  time  symptoms  arise  indicating  the  occurrence  of  hemor- 
rhage, say  from  a  rupture  middle  meningeal,  immediate  interven- 
tion is  indicated.  Some  surgeons  go  so  far  as  to  recommend  tre- 
phining for  every  fracture  of  the  skull  and  exploratory  operation 
in  every  suspected  case,  but  that  seems  at  the  present  time  too 
radical,  especially  for  the  general  practitioner  left  to  his  owm 
resource. 

If  the  fracture  is  comminuted  or  even  only  fissured,  with  depres- 


COMPOUND   FRACTURES    OF    THE    SKULL 


303 


sion,  the  chances  are  so  great  that  there  is  an  injury  to  the  brain 
that  even  with  no  symptoms  present,  immediate  operation  is  indi- 
cated.    (See  Urgent  Craniectomy.) 

COMPOUND   FRACTURES    OF   THE  VAULT 

Much  more  serious  from  every  point  of  view  are  the  compound 
fractures  of  whatever  origin.     The  constant  element  of  danger  is 
infection.     Add  to  this  concussion,  contusion,  or  laceration  of  the 
brain,  and  the  outlook  is  grave 
indeed.     The  treatment  is  not 
so    simple,   but  its  purpose  is 
quite  definite,  viz.:  to  prevent 
infection. 

This  is  accomplished  not  by 
keeping  the  bacteria  out  of  the 
wound — they  -are  already  in; 
not  by  destroying  them  with 
strong  antiseptics,  as  these  are 
too  injurious  to  the  brain  tis- 
sues, but  rather  by  removing 
the  conditions  favorable  to 
bacterial  growth. 

To  this  end  operation  is  im- 
perative. As  in  gunshot  frac- 
tures, enlarge  the  wound,  re- 
move extraneous  matter,  ele- 
vate depressed  fragments,  check  the  hemorrhage  and  remove  clots, 
trim  away  devitalized  tissues  and  provide  drainage  {See  Craniectomy). 
Careful  attention  to  these  details  results  in  the  starvation  of  the 
germs  present,  with  the  result  that  repair  proceeds. 

Skill  in  diagnosis  J  prognosis,  and  treatment  in  fracture  of  the  skull 
depends  upon  a  clear  understanding  of  the  mode  of  causation  and 
the  symptoms  of  contusion,  compression,  and  concussion  of  the  brain. 

Although  presenting  quite  a  diverse  clinical  picture,  separately 
considered,  these  three  conditions  are  nevertheless  of  the  same 
origin  fundamentally.  They  are  each  merely  a  complex  of  symp- 
toms expressing,  on  the  one  hand,  varying  degrees  of  either  functional 


Fig.  231. — Same;  fracture  inner  table. 
Note  greater  comminution  and  depression. 
{Moullin.) 


304  FRACTURES    OF   THE    SKULL   AND   FACE 

depression  or  stimulation  of  the  cortex  of  the  brain  or,  on  the  other, 
of  the  deeper  centers  of  the  cerebrum  and  medulla.  The  cortex  is 
the  seat  of  consciousness  and  at  the  same  time  the  most  sensitive 
part  of  the  brain;  therefore  it  is  the  first  to  be  affected  by  conditions 
disturbing  the  circulation  of  the  brain. 

The  deeper  centers,  those  governing  respiration  and  circulation, 
are  not  so  readily  affected.  The  result  is  that  loss  of  consciousness 
is  the  first  phenomenon  following  a  general  disturbance  of  traumatic 
origin.  This  trauma  may  not  be  sufficient  to  reach  the  cardiac  and 
respiratory  centers  at  first  or  at  all;  or  it  may  only  stimulate  them; 
or  finally  it  may  paralyze  them  as  well  as  the  cortex.  It  must  like- 
wise be  constantly  remembered  that  stimulation  of  these  basal 
centers  means  retardation  of  pulse  and  respiration;  depression  of 
the  same  centers  means  acceleration  of  pulse  and  respiration,  and 
acceleration  is  an  indication  of  approaching  failure. 

It  is  only  by  reference  to  these  first  principles  that  one  may  ex- 
plain and  reconcile  the  variations  in  the  derangements  of  these 
functions  of  consciousness,  circulation,  and  respiration  in  different 
cases. 

CONCUSSION 

This  is  in  all  probability  due  to  a  molecular  disturbance  of  the 
brain  substance,  and  is  accompg,nied  by  neither  microscopic  nor 
macroscopic  change.  The  disturbance  may  be  (a)  moderate,  (b) 
severe,  or  (c)  profound. 

(a)  The  disturbance  is  moderate.  Under  these  circumstances, 
the  trauma  diminishes  the  function  of  the  cortex,  but  does  not  affect 
the  deeper  centers  of  the  brain  and  medulla,  so  there  is  therefore  only 
a  fleeting  loss  of  consciousness  without  any  change  whatever  in  the 
pulse  and  respiration. 

(b)  The  disturbance  is  severe.  The  force  depresses  the  cortex,  but 
only  serves  to  stimulate  the  deeper  centers,  and,  as  before,  there  is 
loss  of  consciousness,  but  there  is  this  time  slowing  of  pulse  and 
breathing.  Very  soon  the  normal  rate  returns  and  a  little  later 
consciousness  is  restored. 

(c)  The  disturbance  is  profound.  The  cortex  is  paralyzed  and 
profoundly  depressed  as  are  also  the  deeper  centers.     The  result 


CONCUSSION  305 

is  U)ss  of  consciousness  and  this  time  rapid  and  weak  pulse  and  shal- 
low breathing  which  may  terminate  very  shortly  in  death.  In 
doubtful  cases,  then,  the  heart  is  the  chief  element  in  prognosis. 
The  pulse  immediately  grows  either  worse  or  better. 

Therefore  the  symptoms  of  concussion  are  distinctly  fugacious. 
This  is  its  chief  criterion. 

If  the  symptoms  once  improve  and  later  recede,  one  may  be  sure 
the  primary  concussion  is  complicated  by  compression  or  contusion. 
Added  to  these  phenomena  of  concussion,  though  not  particularly 
helpful  in  diagnosis  or  prognosis,  are  certain  other  occasional  symp- 
toms, referable  to  the  reflexes. 

In  the  severe  cases  this  will  usually  be  the  picture:  At  the  moment 
of  injury,  unconsciousness  occurs,  immediate  and  complete.  The 
patient  is  more  than  unconscious,  he  is  anesthetized.  The  face  is 
pale  and  sunken  and  the  whole  body  cool.  The  pulse  is  small, 
rapid,  and  irregular.  The  temperature  is  subnormal.  The  breath- 
ing is  shallow  and  sometimes  sighing.  The  urine  and  feces  may  be 
retained  or  pass  involuntarily.  Repeated  vomiting  is  quite  common, 
especially  as  consciousness  begins  to  return.  Following  the  return 
of  consciousness,  a  stage  of  excitement  occurs.  The  symptoms  of 
this  stage  are  those  of  meningeal  irritation,  and  in  uncomplicated 
cases  rapidly  subside. 

The  treatment  is  quite  definite.  Disturb  the  patient  as  little  as 
possible  in  getting  him  into  bed.  Lower  the  head  at  first  and  try 
to  maintain  the  body  heat  with  woolen  blankets  and  hot-water 
bottles.  Carefully  stimulate  the  heart.  To  this  end,  apply  a  mus- 
tard draft  over  the  heart  and  inject  ether  hypodermically  or  a  10 
per  cent,  solution  of  camphorated  oil.  Repeat  these  injections  fre- 
quently, being  guided  by  the  pulse.  Von  Bergmann  recommends 
inhalations  of  ether  for  the  very  weak  and  failing  pulse. 

Do  not  forget  artificial  respiration.  In  those  severe  cases  where 
the  respiration  is  dangerously  low,  it  will  sometimes  tide  the  patient 
over  the  danger-line. 

In  the  subsequent  stage  of  congestion,  keep  the  head  elevated 
and  apply  ice-caps  if  the  dressings  will  permit.     Keep  the  bowels 
open.     If   the  excitement   and  restlessness  are  pronounced,   mor- 
phin  hypodermically  is  indicated. 
20 


3O0  FRACTURES    OF   THE   SKULL   AND   FACE 

COMPRESSION 

Any  condition,  traumatic,  inflammatory,  or  neoplastic,  which 
diminishes  brain  room,  may  induce  symptoms  of  compression  of  the 
brain.  The  symptoms  and  their  course  will  vary  according  to  the 
manner  in  which  the  pressure  is  produced. 

What  is  said  here  applies  particularly  to  the  pressure  symptoms 
originating  in  depressed  fracture  or  traumatic  hemorrhage,  though 
much  would  apply  equally  well  to  the  pressure  of  brain  abscess  or 
brain  tumors,  or  meningeal  exudates  and  similar  conditions. 

Pressure  symptoms  have  fundamentally  the  same  origin  as  con- 
cussion symptoms,  that  is  to  say,  they  are  an  expression  of  de- 
pression or  of  stimulation  of  the  functions  of  the  cortex  and  the  auto- 
matic centers.  In  both  there  may  be  initial  stimulation  and  terminal 
paralysis.  However,  this  depression  or  stimulation  is  produced 
differently  in  the  two  conditions,  concussion  and  compression. 

In  the  first  case,  the  disturbance  of  function  is  brought  about  by 
mechanical  injury  and  in  the  second  by  interference  with  the  blood 
supply.  Sudden  diminution  in  the  circulation  modifies  the  func- 
tional activity  of  the  brain  centers. 

The  cortex,  the  most  sensitive,  is  first  affected,  followed  by  loss  of 
consciousness.  The  automatic  centers  are  next  affected,  at  first 
stimulated,  though  each  reacts  differently;  thus  the  respiratory  center 
is  the  first  to  be  stimulated  and  by  the  presence  of  carbon  dioxide 
which  was  its  primal  stimulus.  The  vaso-motor  centers  are  next 
invaded,  and  finally  the  vagal  and  convulsive  centers. 

In  those  cases  where  the  circulation  becomes  gradually  slower, 
the  order  in  which  these  centers  and  areas  are  successively  affected 
is  as  follows:  the  cortex,  the  corona  radiata,  the  gray  matter  of  the 
spinal  cord,  the  pons,  and  finally  the  medulla.  Now  the  symptoms 
originating  in  these  various  areas  as  a  result  of  pressure  are  of  two 
kinds: 

(a)  General  or  indirect. 

(b)  Focal  or  direct. 

Each  may  manifest  itself  in  two  stages: 

(i)  Stage  of  stimulation. 

(2)  Stage  of  depression  or  paralysis. 


COMPRESSION  307 

It  is  the  knowledge  of  these  facts  which  enables  us  to  harmonize 
and  reconcile  the  diverse  statements  of  various  observers  regarding 
the  character  and  cause  of  the  symptoms  of  compression.  It  is  in 
the  hemorrhage  arising  from  the  middle  meningeal  artery  that  the 
emergency  surgeon  is  chiefly  interested.  Traumatic  compression 
sufficiently  serious  to  require  immediate  operation  in  nine  cases  out 
of  ten  originates  in: 

BLEEDING    FROM   THE    MIDDLE    MENINGEAL   ARTERY 

This  may  follow  injury  to  the  head  with  or  without  fracture.  The 
fracture  may  or  may  not  be  diagnosed. 

In  a  typical  case  the  concussion  symptoms  which  supervened  im- 
mediately upon  the  injury  disappear  after  a  half-hour.  The  patient 
regains  consciousness,  and  the  pulse  and  respiration  approximate 
the  normal. 

In  the  meantime,  however,  the  blood  from  the  torn  meningeal  is 
slowly  oozing  into  the  space  between  the  dura  and  the  skull,  and  the 
''free  interval"  is  interrupted  by  headache,  irritability,  perhaps 
delirium  (stimulation  of  the  cortex).  The  epidural  clot  grows 
larger,  the  intra-cranial  circulation  is  more  impeded  and  complete 
loss  of  consciousness  occurs  (depression  of  the  cortex).  Coincident 
with  this,  the  pulse  grows  slower  and  stronger,  the  respiration  deep 
and  stertorous  (stimulation  of  automatic  centers).  A  little  later 
coma  is  profound,  the  respiration  begins  to  fail,  and  the  heart's 
action  grows  rapid,  weak  and  irregular  (depression  of  both  cortex 
and  automatic  centers),  and  finally  all  the  functions  of  the  entire 
organ  are  suppressed  and  paralyzed,  and  death  ends  the  scene. 

Along  with  these  general  symptoms  there  frequently  occur  at 
various  stages  certain  focal  symptoms,  monospasms,  convulsions; 
monoplegia  or  hemiplegia. 

Usually  at  the  time  the  decision  to  operate  is  made,  this  will  be  the 
condition  of  the  patient:  He  lies  inert,  unconscious,  the  pulse  full 
and  bounding,  the  respiration  deep  and  stertorous,  the  skin  hot  and 
perspiring,  the  pupils  irregular,  usually  dilated  on  the  side  of  com- 
pression, partial  or  complete  hemiplegia  of  the  opposite  side. 

Treatment. — With  a  definite  diagnosis  once  made,  there  is  no 


3o8  FRACTURES    OF    THE    SKULL    AXD    FACE 

difference  of  opinion  as  to  the  treatment.  It  is  imperative  to  operate, 
and  to  do  so  without  delay.  Every  additional  hour  adds  to  the 
certainty  of  a  fatahty.  The  nature  of  the  injury  and  the  focal 
symptoms  point  to  the  site  of  the  clot  or  the  branch  of  the  meningeal 
most  probably  involved. 

By  trephining,  the  clot  is  exposed,  and  removed,  and  the  bleeding 
vessel  discovered  and  ligated.     (See  Craniectomy.) 

The  pressure  symptoms  of  hemorrhage  from  injuries  of  the  sinsues 
are  identical  with  those  from  meningeal  bleeding  except  that  they 
develop  much  more  slowly  and  are  likely  not  to  be  so  t}'pical. 
Hemiplegia  is  not  always  in  the  side  opposite  the  clot. 

FRACTURE  OF  THE  SUPERIOR  M.\XILLA 

Fracture  of  the  superior  maxilla  occurs  alone  or  with  fracture  of 
the  malar  or  other  bones  of  the  face.  It  may  be  accompanied  by 
splintering  of  the  bone,  caving  of  the  antrum,  loosening  of  the  teeth, 
and  disfigurement  generally.  The  alveolar  process  may  be  broken 
off.     If  this  is  the  case,  it  may  be  replaced  without  great  difficulty. 

Oftentimes  little  can  be  done  to  correct  the  deformity.  The  low^er 
jaw  can  be  used  as  a  splint  and  very  little  force  is  needed  to  retain 
the  fragments  in  position. 

If  the  fracture  is  compound,  the  fragments  should  be  treated  con- 
servatively. It  is  surprising  how  perfectly  they  may  sometimes  be 
repaired.  The  vascularity  of  both  bone  and  periosteum  favors  this 
result. 

With  the  jaw  at  rest,  a  liquid  diet  should  be  maintained,  frequently 
cleansing  the  mouth  with  alkaline  antiseptic  fluids.  Be  on  guard  for 
fracture  of  the  base  of  the  skull. 

FRACTURE  OF  THE  AUALAR  BONE 

Fracture  of  the  malar  bone  seldom  follows  the  suture  lines.  The 
whole  bone  may  be  dislocated  in  a  direction  corresponding  to  the 
force.  In  this  manner,  the  violence  may  be  transmitted  to  the  supe- 
rior maxilla,  its  sinus  and  infra-orbital  canal,  to  the  nose,  the  orbit, 
or  to  the  base  of  the  skull. 


FRACTURE   OF   THE   LOWER   JAW  309 

Uncomplicated  fractures  of  the  malar  bones  require  little  treat- 
ment.    Compound  fractures  must  be  treated  on  general  principles. 

It  may  be  possible  to  replace  a  depressed  fracture  of  the  zygomatic 
process  by  pressure  through  the  mouth. 

FRACTURE  OF  THE  NASAL  BONE 

Aside  from  gunshot  fractures  (see  page  190),  the  bones  of  the  face 
suffer  occasionally  from  direct  violence. 

The  nasal  hones  may  be  fractured  alone  or  in  connection  with  the 
ethmoid.  Bleeding  is  profuse  and  deformity  apparent.  On  account 
of  infection  from  either  the  outside  or  inside  of  the  nasal  cavity, 
inflammation  and  necrosis  may  be  a  sequela. 

An  attempt  should  be  made  at  once  to  elevate  the  depressed  frag- 
ments by  pressure  within  the  nasal  cavity.  The  reduction  may  be 
both  difficult  and  painful.     General  anesthesia  may  be  necessary. 

Check  the  hemorrhage  by  mopping  the  nasal  cavity  with  a  solution 
of  adrenalin  chloride,  or  pack  temporarily  with  sterile  gauze.  Sub- 
sequently douche  the  nasal  cavity  frequently  with  glycothymoline  or 
Seller's  solution  to  prevent  infection. 

FRACTURE  OF  THE  INFERIOR  MAXILLA 

Fractures  of  the  inferior  maxilla  occur  most  frequently  just  in 
front  of  the  mental  foramen,  and  are  usually  compound,  opening  into 
the  mouth. 

The  deformity  is  determined  chiefly  by  muscular  action  and  the 
degree  of  obliquity. 

The  diagnosis  is  rarely  difficult. 

Reduction,  which  is  indicated  by  a  correct  alignment  of  the  teeth, 
may  be  accomplished  by  bimanual  manipulation  with  the  fingers  of 
one  hand  in  the  mouth.  This  is  usually  easily  done,  the  chief  diffi- 
culty being  to  retain  the  fragments  in  position.  The  prevention  of 
infection  is  likewise  important  (Fig.  232). 

Oliver,  of  Indianapolis  (Ind.  Med.  Journal,  1906),  has  described 
the  mode  of  treatment  most  applicable  in  the  emergencies  of  general 
practice.     He  recommends,  as  the  result  of  his  experience,  that  in 


3IO 


FRACTURES    01"    THE   SKULL   AND   FACE 


the  ordinary  case,  when  the  patient  retains  the  majority  of  his  teeth, 
the  upper  jaw  be  used  as  a  spHnt. 

This  is  his  procedure:  before  attempting  reduction  and  without 
anesthesia,  if  possible,  he  begins  by  passing  a  loop  of  wire  (soft  iron 
wire,  gauge  26  or  28)  around  the  neck  of  the  most  available  tooth 
behind  the  break  in  the  lower  jaw;  a  similar  loop  is  thrown  around  the 
corresponding  tooth  in  the  upper  jaw.  Coming  forward  of  the  frac- 
ture the  first  solid  tooth  and  its  fellow 
above  are  both  looped  in  the  same 
manner. 

Next  a  similar  loop  is  adjusted 
above  and  below  on  the  opposite  side 
of  the  jaw — on  the  sound  side.  Alto- 
gether six  separate  wires  have  been 
used.  Each  loop  is  now  twisted  down 
tight  with  a  pair  of  pliers,  so  that  the 
teeth  are  firmly  encircled  and  the  free 
ends  of  the  wires  left  projecting  from 
the  mouth  (Fig.  233). 

Reduce  the  fracture  as  the  next  step. 
This  is  done  by  pressure  and  traction 
wdth  the  fingers  inside  and  outside  of 
the  mouth. 

Immohilize. — 'This  is    accomplished 
by  twisting  firmly  together  by  means 
of  the  pliers  the  corresponding  upper  and  lower  wires,  which  brings 
the  lower  jaw  into  intimate  contact  with  the  upper. 
Liquid  diet  sucked  through  the  teeth. 

Antisepsis. — Direct  the  patient  to  fill  his  mouth  with  the  antiseptic, 
fluid  and  to  churn  it  vigorously  backward  and  forth  between  the 
teeth.  This  washing  should  be  done  frequently  each  day,  and 
especially  after  each  feeding.  If  necessary,  as  additional  support, 
a  plaster-of-Paris  or  Barton's  bandage  may  be  applied. 

The  wires  are  left  for  three  weeks,  or  longer  in  the  severe  cases, 
and  after  their  removal  a  bandage  should  be  kept  on  for  another 
week.  The  patient  should  be  supplied  with  a  small  pair  of  wire 
cutters  and  direct  how  to  use  them  in  an  emergency,  such  as  serious 
vomiting  which  might  result  in  asphyxia. 


Fig.  2^2. — Fracture  of  lower  jaw. 
Temporary  bandage.      (Moullin.) 


SUTURING   FRACTURE    OF    THE   JAW  3II 

As  Oliver  observes,  this  formula  may  be  varied  to  suit  ihe  indi- 
vidual case.  The  many  forms  of  splints  need  not  be  here  considered. 
The  cases  of  special  difficulty  in  reducing  and  retaining,  those  which 
are  compound  and  those  in  jaws  practically  edentulous,  require 
wiring.  This  is  an  operation  simple  in  theory,  but  more  difficult  in 
practice. 


Fig.  233. — -Wiring  the  teeth  for  fracture  of  the  lower  jaw.  Note  the  manner  in  which 
the  wires  encircle  the  upper  and  lower  teeth  before  and  behind  the  line  of  fracture.  The 
upper  wire  is  subsequently  twisted  with  its  corresponding  wire  below,  so  that  the  lower  jaw 
is  splinted  against  the  upper. 

The  main  points  are  to  make  the  incision  along  the  lower  border 
of  the  jaw,  cutting  to  the  bone  and  letting  the  middle  of  the  incision 
fall  over  the  line  of  fracture.  The  bone  is  carefully  denuded  of 
periosteum.  The  sutures  are  not  to  come  in  contact  with  the  buccal 
surfaces.  The  bones  are  drilled;  the  sutures  passed  and  tied,  the 
periosteum  drawn  over  the  sutures,  and  the  soft  parts  partially 
repaired. 


CHAPTER  XVIII 

INJURIES  TO  JOINTS 

Dislocations ;  Compound  Dislocations ;  Open  Wounds ;  Contusions ; 

Sprains 

DISLOCATIONS 

Shoidder-joint.—Oi  all  the  joints,  the  shoulder  is  by  far  the  most 
frequently  dislocated.  Of  these  dislocations,  there  are  several  forms, 
and  yet  only  one  variety  is  likely  to  be  met  with  by  the  general  prac- 
titioner— the  sub-coracoid.  A  clear  conception  of  the  conditions  and 
of  the  maneuvers  necessary  to  a  reduction  presupposes  a  very  defi- 
nite notion  of  the  anatomy  of  the  joint. 

Recall  the  relation  of  the  acromion  and  coracoid  processes  to  the 
glenoid  fossa,  to  the  head  of  the  humerus  and  to  the  capsular  liga-^ 
ment;  the  relation  of  the  long  head  of  the  biceps  to  the  joint  and  the 
attachments  and  actions  of  the  various  muscles  surrounding  the 
joint,  particularly  the  subscapularis,  the  spinati,  the  pectoralis 
major;  and  the  relations  of  the  axillary  vessels  and  nerves. 

However  simple  a  case  may  appear,  do  not  begin  any  maneuver 
until  a  complete  diagnosis  has  been  made. 

Diagnosis. — Begin  by  inspection.  The  patient  is  in  evident  pain; 
his  head  is  inclined  to  the  injured  side  and  he  supports  the  injured 
member  with  the  other  hand;  the  shoulder  is  flattened,  the  rounded 
prominence  of  the  deltoid  has  disappeared  and  the  acromion  projects; 
the  elbow  is  abducted  and  the  patient  is  unable  to  bring  it  down  to 
the  side. 

Palpation  reveals  the  axis  of  the  humerus  pointing  to  the  middle  of 
the  clavicle;  the  examining  finger  can  be  pushed  under  the  acromion 
where  the  humeral  head  should  be.  The  humeral  head  itself  may  be 
felt  below  or  to  the  inside  of  the  coracoid,  and  rotates  with  slight 
rotation  of  the  arm. 

312 


DISLOCATION    OF    THE   SHOULDER  313 

The  lingers  in  the  axillary  space  feel  the  rounded  head  of  the  hu- 
merus projecting  inward  more  noticeably  when  the  arm  is  slightly 
abducted. 

These  questions  arise:  "Is  it  a  case  of  simple  dislocation,  or  is  it 
complicated  by  a  fracture  of  the  upper  end  of  the  humerus,  of  the 
great  tuberosity,  or  the  rim  of  the  glenoid  fossa?"  ''Have  the  arter- 
ies or  nerves  been  injured?"  You  must  test  particularly  for  lacera- 
tion of  the  circumflex  nerve.  Do  this  by  pin  pricks  over  the  deltoid; 
if  the  skin  is  insensitive,  forecast  paralysis  and  atrophy  of  the  deltoid, 
and  thus  anticipate  and  disarm  censure. 

Whether  any  of  the  other  complications  mentioned  are  present 
or  not  is  to  be  determined  by  the  methods  already  described  in  con- 
nection with  fractures  of  the  upper  end  of  the  humerus. 

Reduction. — (Lejars.)  The  method  of  Kocher  seldom  fails,  if 
properly  applied,  and  if  the  various  movements  are  modified  to  suit 
the  individual  case.  Its  purpose  is  to  put  the  head  of  the  humerus 
in  the  position  at  which  it  left  the  capsule.  Through  the  relaxed 
tear  the  head  is  then  to  be  levered  into  the  socket. 

Seat  the  patient  in  a  chair  facing  a  little  to  one  side.  Let  a  strong 
and  able  assistant,  standing  behind,  seize  the  patient's  shoulder 
firmly  and  make  pressure  downward  and  backward.  Place  yourself 
before  the  dislocation,  and  seizing  (in  the  case  of  the  left  arm)  the 
forearm  at  the  elbow  wdth  the  left  hand,  and  the  wrist  with  the  right 
hand,  direct  the  patient  to  hold  the  head  up  and  look  straight  ahead. 

First  Stage:  Flexion,  Adduction. — The  elbow  is  flexed  and  then 
gradually  adducted  until  it  touches  the  body,  the  wrist  held  firmly 
meanwhile.  The  elbow  is  now  pushed  backward  beyond  the  axillary 
line — the  first  stage  is  not  complete  without  this.  Neglecting  this 
part  of  the  first  maneuver  is  a  frequent  cause  of  failure.  Do  not 
get  in  too  great  a  hurry.  Remember  that  the  larger  part  of  the  re- 
sistance is  due  to  the  muscles  and  that  they  yield  only  gradually. 
Too  sudden  and  too  violent  traction  on  them  augments  the  pain  and 
their  resistance.  To  pause  a  little  now,  gives  them  time  to  relax 
(Fig.  234). 

Second  Stage:  External  Rotation. — Hold  the  elbow  fast  and  flexed 
at  a  right  angle,  and  now  with  your  right  hand,  swing  the  forearm 
outward  and  backward  until  it  lies  in  the  transverse  vertical  plane 


314 


INJURIES    TO   JOINTS 


of  the  body  (Fig.  235).  Its  axis  lies  directly  in  front  of  you.  Per- 
form the  maneuver  cautiously  and  smoothly.  Again  pause  until 
the  muscles  are  relaxed.  Do  not  be  alarmed  by  the  snapping  dis- 
tinctly heard  in  the  movement.     One  may  follow  the  movement 


Fig.  234.— Reduction  of  shoulder.      First  stage:    Flexion;  adduction;  elbow  a  little 
posterior  to  the  axillary  line. 


of  the  bulging  head  of  the  humerus  with  the  eye.  Occasionally 
reposition  occurs  at  the  end  of  this  movement,  if  it  has  been  carried 
out  methodically.  If  it  has  not  proceed  to  the  third  stage  of  the 
maneuver. 


DISLOCATION    OF    THE   SHOULDER 


315 


Third  Stage:  Elevation. — Maintaining  flexion  and  external  rota- 
tion, next  lift  the  elbow  upward  and  forward — upward  and  forward 
exactly — do  not  permit  the  elbow  to  move  outward.  Abduction 
will  spoil  the  maneuver  (Fig.   236).     Lift  upward  and  forward  till 


Fig.   235. — Reduction  of  shoulder.     Second  stage:    External  rotation  until  fore- 
arm stands  at  right  angle  to  body. 


the  arm  reaches  the  horizontal — a  sudden  snap  indicates  that  the 
head  has  slipped  into  the  socket. 

Fourth  Stage:  Internal  Rotation. — Proceed  now  rapidly  to  swing 
the  forearm  inward  and  across  the  chest  until  the  hand  rests  on  the 


3i6 


INJURIES   TO   JOINTS 


opposite  shoulder  (Fig.  237).  The  movement  is  made  rapidly  but 
with  no  great  force.  This  latter  holds  good  with  respect  to  all  the 
movements.  It  must  be  observed  that  the  surgeon's  hands  do  not 
change  their  hold  at  any  stage  of  the  reduction. 


Fig.   236. — Reduction  of  shoulder.     Third  stage:  Elevation  while  maintaining 

external  rotation. 


If  these  maneuvers  fail,  repeat  them  in  the  same  order,  using  a 
little  more  force  in  the  second  and  third  stages  and  pausing  a  Uttle 
longer  at  the  end  of  a  stage. 

In  the  suhclamcular  form  also  this  maneuver  will  succeed,  but 


DISLOCATION    OF    THE    SHOULDER 


317 


should  be  modiliccl  to  this  extent:  prolong  the  second  stage  two  or 
three  minutes,  using  more  force  to  obtain  external  rotation  and  the 
backward  position  of  the  elbow.     In  this  wise,  the  muscles  are  re- 


FiG.   237. — Reduction  of  shoulder.     Fourth  stage.     Internal  rotation. 


taxed  more  completely.     Without  changing  the  external  outward 
rotation,  the  elbow  is  lifted  upward  and  forward  as  before. 

Not  less  efficient  in  certain  cases  of  subcoracoid  dislocation  is  the 
method  oj  Mothe,  or  traction  in  extreme  abduction.  It  is  also  applicable 
in  all  other  forms  of  inward  and  downward  dislocation. 


3i8 


INJURIES    TO   JOINTS 


In  this  procedure,  counter-extension  is  indispensable.  A  long  towel 
will  serve.  It  encircles  the  injured  shoulder,  passing  under  the  arm- 
pit, and  the  two  ends  cross  the  back  toward  the  south  side.  While 
the  assistant  makes  forcible  counter-extension,  the  operator  manipu- 


FiG.  238. — Reduction  of  shoulder.     Traction  with  high  abduction.      The  axis  of  the  humerus 
should  be  in  line  with  the  spine  of  scapula.     Assistant  steadies  the  shoulder. 


lates  the  arm.  It  is  best  that  he  stand  on  a  stool  or  chair  if  not  tall 
enough  to  make  good  traction  upward.  Now  seize  the  arm  above 
the  elbow  and  the  forearm  near  the  wrist  (Fig.  238).  Flex  the  elbow. 
Next  elevate  the  arm  by  extreme  abduction  until  it  is  in  line  with  the 
spine  of  the  scapula.     The  arm,  you  must  observe,  does  not  reach  the 


DISLOCATION    OF    THE   SHOULDER 


319 


horizontal  merely,  it  is  elevated  beyond  that  level.  This  is  of  the 
greatest  importance.  With  the  arm  thus  in  extreme  abduction,  next 
make  strong  traction  in  that  direction  (Fig.  239).  Assistance  in  trac- 
tion may  be  necessary;  or  one  may  confide  the  traction  to  an  assistant, 


Fig.   239. — Reduction  by  high  abduction  and  traction.     Note  manner  in  which  the  assistant 

steadies  the  shoulder.     (Lejars.) 


while  with  the  thumbs,  one  pushes  against  the  humeral  head  in  the 
axillary  space. 

If  this  does  not  succeed,  begin  the  second  stage: 

Depress  the  arm  rapidly  and  smoothly,  letting  the  point  of  the 
elbow  pass  in  front  of  the  chest,  all  the  while  maintaining  traction. 
This  method  occasionally  fails  for  these  reasons: 

(i)  Traction  with  high  abduction  is  not  long  enough  continued. 


320 


IN'JURIES    TO    JOINTS 


The  arm  is  depressed  before  the  head  has  been  sufficiently  elevated  by 
traction. 

(2)  The  arm  is  lowered  too  slowly. 


Fig.  240. — Chipman's  method  of  reducing  dislocated  shoulder.     First  stage. 
{International  Journal  of  Surgery.) 

In  neglected  cases  or  in  the  very  muscular,  general  anesthesia  may 
be  indispensable  whatever  the  method,  but  force  must  then  be  em- 
ployed w^ith  still  greater  care,  and  it  must  be  borne  in  mind,  too,  that 
incomplete  anesthesia  here  is  as  dangerous  as  it  is  useless.  The  par- 
ticular danger  of  this  method  is  laceration  of  the  axillary  structures. 
If  general  anesthesia  is  strongly  contra-indicated,  local  anesthesia 


DISLOCATION   OF    THE    SHOULDER 


321 


may  be  employed,  injecting  the  joint  and  the  tendons  near  their  lines 
of  insertion.  How  long  after  the  injury  reduction  may  be  attempted 
cannot  be  determined  by  any  rule,  but  by  the  conditions  in  the 
individual  case. 


Fig.  241. — Chipman's  method  of  reducing  dislocated  shoulder.     Second  stage. 
{International  Journal  of  Surgery.) 


Chipman,  of  New  London,  Connecticut,  suggests  a  method  which 
must  prove  of  value,  especially  to  the  doctor  compelled  to  act  without 
assistance. 

He  describes  his  method  thus  (Int.  Journal  of  Surgery,  November, 
1906):  Stand  facing  your  patient.     Gradually  raise  the  dislocated 


21 


322 


INJURIES   TO   JOINTS 


arm  to  a  horizontal  position  and  place  it  on  your  shoulder  with  fore- 
arm flexed  on  your  back.  Direct  the  patient  to  pass  the  well  arm 
under  your  arm  and  grasp  the  wrist  of  the  injured  arm  with  the  well 
hand.  Thus  the  patient's  arms  encircle  your  body,  the  injured  one 
passing  over  one  shoulder,  the  sound  passing  under  the  other  (Fig. 
240). 

Second  Stage. — Now  direct  the  patient  to  sag  downward,  and  the 
weight  of  the  body  drags  the  head  of  the  humerus  outward  and  up- 
ward, when  you  can  easily^l*■eturn  it  to  the  glenoid  cavity  with  your 
hands  (Fig.  241).     The  dislocation  is  so  easily  and  expeditiously  re- 


Suh-coramd 


Fig.  242. — Dislocation  of  shoulder.     {Walsham^ 

duced  that  even  the  surgeon  himself  is  surprised.  There  is  the  least 
possible  additional  injury,  the  least  possible  pain;  there  is  no  need  of 
an  assistant  or  an  anesthetic. 


SUBGLENOID   DISLOCATION 

This  variety  is  always  the  result  of  forcible  abduction  of  the  hu- 
merus, the  tear  in  the  capsule  falling  below  the  glenoid  cavity,  and 
the  head  of  the  humerus  remaining  fixed  there  (Fig.  242). 

The  diagnosis  is  to  be  made  from  the  symptoms  already  described 
for  the  subcoracoid  form,  the  only  difference  being  that  the  elbow 
is  further  from  the  chest,  the  flattening  of  the  shoulder  more  pro- 


SUBGLENOID   DISLOCATION 


323 


nounced,  the  head  of  the  humerus  more  readily  felt  in  the  axilla 
(Fig.  243). 

The  reduction  may  be  affected  by  Kocher's  method,  but  perhaps 
the  best  method  is  that  of  extreme  abduction  with  traction,  which  has 


Fig.  243. — Reduction  of  a  subglenoid  dislocation.     Second  stage.     Gradual 
elevation  with  constant  traction. 


already  been  described.  The  patient  may  be  seated,  but  often  must 
rechne,  for  the  weight  of  the  pendent  limb  may  be  very  painful.  The 
injured  member  is  grasped  above  the  elbow  with  one  hand,  below  the 
wrist  with  the  other,  flexed,  slowly  raised  to  form  an  obtuse  angle 


324 


INJURIES    TO   JOINTS 


with  the  chest.  In  this  position  strong  traction  and  counter-traction 
are  to  be  made.  Usually  this  succeeds,  though  it  may  help  to  press 
the  head  into  place  (Fig.  244).     If  traction  and  pressure  are  not  suf- 


FiG.   244. — Reduction  of  subglenoid  dislocation.      Third  stage.     Traction  with    high     ab- 
duction and  pressure  on  the  humeral  head. 

ficient  to  effect  reduction  after  the  muscles  have  been  thoroughly 
relaxed,  the  arm  is  to  be  depressed  as  before  described. 

Subspinous  Dislocation. — In  this  case  the  shoulder  is  flattened  in 
front  and  the  examining  finger  finds  a  marked  depression  between  the 
tip  of  the  acromion  process  and  the  coracoid.     The  elbow  is  carried 


SUBSPINOUS   DISLOCATION  325 

slightly  forward  and  the  arm  rotated  inward.     The  head  of  the  hu- 
merus can  be  felt  below  the  spine  of  the  scapula. 

Reduction. — General  anesthesia  is  usually  necessary.  Grasp  the 
arm  above  the  elbow;  slightly  abduct  the  arm;  slightly  increase  the 
inward  rotation  (never  rotate  outward);  make  traction  in  a  direction 
downward  and  forward.     Pressure  forward  on  the  head  is  helpful. 

AFTER-TREATMENT    OF    SHOULDER   DISLOCATIONS 

The  task  in  any  form  of  dislocation  does  not  end  with  reduction. 
There  is  still  the  duty  to  restore  usefulness  as  completely  as  possible, 
and  to  that  end  the  subsequent  care  must  be  minutely  regulated. 
The  inclination  is  to  immobilize  the  joint  too  completely  and  too 
long,  fearing  a  recurrence  of  the  dislocation.  This  enforced  rest  com- 
bined with  injury  is  Hable  to  produce  atrophy  of  the  muscles,  stiffness 
of  the  joint,  and  protracted  loss  of  function.  The  indications  for 
after-treatment  are  various,  depending  upon  clinical  conditions. 

(A)  An  uncomplicated,  easily  reduced  dislocation  in  a  healthy 
strong  adult: 

Begin  by  immobilizing  the  shoulder,  but  take  care  that  after  three 
or  four  days  of  complete  rest  massage  and  passive  motion  shall  be 
begun.  The  joint  is  cautiously  put  through  all  its  motions,  the  del- 
toid, and  pectoraUs  major,  and  the  scapular  muscles  carefully  mas- 
saged; a  daily  seance  gradually  prolonged. 

In  the  interval  the  arm  is  bandaged,  but  gradually  the  dressing  is 
relaxed  and,  after  a  week,  movement  left  quite  free.  In  two  weeks 
of  such  treatment  the  function  may  be  entirely  restored. 

(B)  The  case  was  compUcated  with  injury  to  the  soft  parts,  was 
with  difficulty  reduced,  and  only  after  a  number  of  attempts;  it  is 
likely  that  the  capsular  ligament  was  extremely  lacerated: 

Under  such  circumstances  not  only  partial  displacement,  but 
actual  dislocation  is  to  be  feared.  Immobilize  the  joint  with  a  Mayor 
sUng  or  Velpeau  bandage  and  let  it  so  remain  a  week.  But  this  will 
not  prevent  massage  over  the  shoulder  after  four  or  five  days.  Do 
not  prolong  the  fixation,  remembering  that  a  dislocation  accompanied 
by  great  violence  furnishes  the  condition  most  favorable  to  adhesions 
and  weakness,  and  against  these  evils  we  have  no  remedies  but  mas- 
sage and  gymnastics,  which  must  be  early  begun  and  long  continued. 


326 


IN'TURIES    TO   JOINTS 


A  man  was  brought  to  the  City  Hospital  -^ith  a  pronounced  sub- 
coracoid  dislocation.  The  radiograph  showed  a  part  of  the  greater 
tuberosity  scaled  ott.  The  injury  was  a  crushing  one,  a  great  stack 
of  sacks  filled  with  flour  ha\-ing  toppled  over  and  pinned  him  against 
the  wall.  The  tendon  of  the  biceps  was  probably  torn  from  its  groove 
carn-ing  a  fragment  of  bone  with  it.  Under  general  anesthesia  the 
dislocation  was  easily  reduced  by  traction  with  high  abduction  com- 
bined with  pressure  on  the  head  of  the  humerus.  After  two  weeks, 
immobilization  the  tenderness  on  pressure  over  the  greater  tuber- 
osity was  still  marked  and  it  was  assumed  that  the  fragment  was  not 

vet  reunited.     Movement  at  the 


K^^^ 


elbow  also  excited  pain  at  the 
shoulder.  After  another  ten 
days'  massage  and  passive  mo- 
tion was  tried  again  with  better 
results  and  at  the  end  of  five 
weeks  he  had  regained  the  func- 
tions of  the  joint  in  fair  degree. 


DISLOCATIOX  OF  THE 
LOWER  JAW 

This  accident,  which  may  hap- 
pen at  most  unexpected  times, 
when  yawning  or  laughing,  for 
instance,  might  be  confused  with 
/  ^^       ^  \(^        '        ^       certain  fractures  of  the  inferior 
H       I  U  maxilla.    The  opened  mouth,  the 

Pig    245.— Dislocation  of  jaw.     {MouUin.)       loSS     of     powei     tO     close    it,    are 

characteristic  (Fig.  245").  The 
reduction  is  usually  easy.  Both  sides  may  be  reduced  simulta- 
neously. Wrap  the  thumbs;  you  have  to  deal  with  the  powerful 
muscles  of  mastication,  which,  when  the  dislocation  is  reduced,  are 
likely  to  close  the  jaws  \\'ith  much  force. 

The  thumbs,  passed  into  the  mouth,  press  downward  and  backward 
on  the  molar  teeth;  at  the  same  time,  the  fingers  hooked  under  the 
chin  pull  upward.     In  the  muscular,  considerable  force  is  required. 

The  jaws  should  be'moved  only  sHghtly  for  several  days. 


DIAGNOSIS   OF   ELBOW  DISLOCATION 


DISLOCATION  OF  THE  ELBOW 


327 


Dislocation  of  the  elbow,  which  occurs  with  considerable  frequency, 
especially  in  children,  nearly  always  assumes  the  form  ot  backward 
displacement. 


Fig.  246. — Reduction  of  the  elbow-joint.     Traction  with   gradual  flexion  combined  with 

pressure  forward  on  the  olecranon. 


Diagnosis: — The  elbow  is  increased  in  thickness  antero-posteriorly. 
The  flexure  of  the  joint  is  depressed.  Where  the  head  of  the  radius 
should  be  there  is  a  depression.     The  olecranon  is  abnormally  promi- 


328  INJURIES    TO   JOINTS 

nent.  Compare  the  relation  of  the  olecranon  to  the  inner  condylar 
Unes  on  the  two  sides.  Flexion  is  quite  painful  and  practically 
impossible. 

If  the  diagnosis  is  doubtful,  as  it  often  must  be  when  swelUng  is 
great,  one  thinks  of  supra-condylar  fracture.  But  in  the  case 
of  fracture,  the  relation  of  the  olecranon  to  the  condylar  hne  is 
unaltered;  the  humerus  is  shortened;  the  deformity  disappears  with 
traction. 

Reduction. — (A)  Standing  on  the  injured  side,  seize  the  arm  above 
the  elbow  with  both  hands,  and  as  an  assistant  makes  traction  on  the 
forearm,  steady  the  arm  and  press  with  both  thumbs  on  the  olecranon. 
The  traction  is  made  at  first  in  the  direction  of  the  long  axis  of  the 
forearm,  but  as  the  limb  yields,  the  forearm  is  rapidly  flexed — con- 
tinuing the  traction  and  pressure.  By  this  means  reposition  is  usu- 
ally quite  easy  (Fig.  246). 

Traction  and  counter-traction  as  before,  except  that  the  traction 
which  began  in  the  direction  of  the  long  axis  of  the  forearm  and  pro- 
duced flexion,  now  produces  hyper-extension.  In  the  meantime, 
press  on  the  olecranon  and  the  head  of  the  radius.  In  this  way,  one 
wdll  sometimes  succeed,  but  do  not  forget  this  method  is  available 
only  for  those  who  have  supple  joints. 
(C)  Method  of  Astley  Cooper: 

The  patient  is  seated  on  a  chair — you  place  yourself  on  the  side 
opposite  the  injured  elbow.  If  it  is  the  right,  for  example,  stand  upon 
the  left  side  and  place  a  foot  upon  the  chair.  Get  the  bend  of  the  el- 
bow over  the  knee.  Steadying  the  humerus  with  one  hand,  draw  on 
the  flexed  forearm  with  the  other,  at  the  same  time  flexing  the  elbow 
over  the  knee. 

Generally  speaking,  however,  if  the  first  method  fails,  it  is  bet- 
ter to  give  a  general  anesthetic,  with  which  the  chief  difficulties 
disappear. 

Lateral  dislocations  are  usually  replaced  without  much  trouble  by 
pressure  combined  with  extension. 

After-treatment. — This  must  be  begun  even  earlier  than  for  the 
shoulder — massage  and  passive  motion — else  a  stiff  joint  is  very 
likely  to  follow. 


CLASSES    OF   THUMB    DISLOCATION 


329 


DISLOCATION  OF  THE  THUMB 

This  accident,   apparently   simple,   presents   some   peculiarities 
which  must  be  borne  in  mind. 

These  displacements  at  the  metacarpo- 
phalangeal joint,  are  classified  as  incom- 
plete, complete,  and  complicated,  de- 
pending upon  the  relations  which  the 
articular  surfaces  assume  and  upon  the 
disposition  of  the  sesamoid  bone  (Fig. 
247).  Incotnplete  dislocations  leave  the 
articular  surfaces  in  slight  contact;  com- 
plete dislocations  find  the  articular  sur- 
faces at  right  angles,  the  phalanx  stand- 
ing upon  the  dorsum  of  the  metacarpal 
(Fig.  248);  and,  if  in  addition  to  this,  the 
torn  anterior  ligament  and  sesamoid 
bone,  in  attempt  at  flexion,  are  w^edged 
between  the  articular  surfaces,  the  dislo- 
cation is  said  to  be  complicated,  a  condi- 
tion difficult  to  manage  (Fig.  249).  Since 
this  condition  is  produced  by  maladroit  attempts  at  reduction  of 


Fig.  247. — Complete  dislocation 
of  thumb.      (Moullin.) 


iM 


Fig.  248. — Complete     dislocation 
of^thumb.      {Moullin.) 


Fig.    249. —  Complicated    dislo- 
cation    of     thumb.      (Moullin.) 


the   complete   dislocation,   it  is  especially  desirable  to  understand 
the  maneuvers. 


S3°  .  INJURIES   TO   JOINTS 

Whether  the  dislocation  be  complete  or  incomplete,  never  attempt 
reduction  by  flexion.  That  is  the  thing  to  be  avoided.  Seize  the 
thumb  and  slightly  bend  it  still  further  backward,  at  the  same  time 
pushing  the  base  of  the  phalanx  obliquely  downward  and  forward. 
Directly  the  phalanx  will  be  felt  to  slide  over  the  head  of  the  meta- 
carpal into  its  place. 

Complicated  Dislocation. — (Lejars.)  Employ  general  anesthesia. 
Only  the  most  carefully  regulated  maneuvers  will  succeed.  Do  not 
attempt  the  reduction  unless  the  various  steps  are  clearly  in  mind. 

(i)  Make  traction  on  the  digit  in  the  direction  of  its  axis  until  it 
is  as  long  as  normal. 

(2)  Seizing  the  thumb  between  forefinger  and  thumb  in  such  man- 
ner that  your  thumb  presses  on  the  dorsal  surface  of  the  dislocated 
joint,  bend  it  backward  until  it  stands  perpendicular  to  the  meta- 
carpal, or  even  further.  The  object  is  to  put  the  thumb  in  the  posi- 
tion of  uncomplicated  dislocation,  and  thus  disengage  the  sesamoid 
bone. 

(3)  Still  holding  it  at  that  angle,  push  the  base  of  the  phalanx 
forward. 

(4)  Having  pushed  the  phalanx  as  far  forward  as  possible  in  this 
manner,  begin  suddenly  to  flex  it,  in  the  meantime  keeping  the  last 
phalanx  extended  and  do  not  cease  to  push  forward  while  flexing. 

If  failure  attends  two  or  three  attempts,  do  not  persist;  proceed 
to  operate. 

Dislocations  of  thefingtrs  should  be  treated  in  the  same  manner — 
never  begin  by  flexing. 

Reduce  by  first  bending  the  finger  backward  and  then  pushing 
the  base  of  the  phalanx  forward.  In  every  case  the  purpose  is  to 
reproduce  in  reduction  the  movements  of  dislocation. 

DISLOCATION  OF  THE  HIP 

These  accidents  are  always  serious,  and  yet  are  comparatively  rare. 
Of  the  different  forms  of  luxation  of  the  femoral  head,  the  backward 
on  the  dorsum  iUi  is  by  far  the  most  frequent  (Figs.  250,  251). 

Diagnosis. — The  thigh  is  adducted,  rotated  inward,  and  practically 
immovable.     The  leg  is  apparently  shortened,    the  knee   slightly 


DISLOCATION    OF    THE   inP 


331 


flexed.  The  trochanter  rests  above  the  line  drawn  from  the  spine 
of  the  ilium  to  the  ischial  tuberosity.  The  femoral  head  may  be 
felt  under  the  gluteal  muscles  on  the  dorsum  ilii. 

Reduction. — General  anesthesia  is  usually  necessary.  Lay  the 
patient  on  a  pallet  on  the  floor.  A  strong  assistant,  pressing  on  the 
iliac  spines,  immobilizes  the  pelvis. 

First  Movement:  Flexion  of  Thigh. 
— Grasp  the  thigh  above  the  knee 
with  one  hand  and  with  the  other, 
the  leg,  and  gradually  flex  the  hip 
and  knee.  Flex  the  hip  to  a  right 
angle. 

Second  Movement:  Traction  on 
the  Flexed  Femur. — When  the  hip 
is  flexed  at  a  right  angle,  begin 
traction,  maintaining  that  angle. 
Do  not  be  afraid  to  use  force. 
This  is  the  most  important  man- 
euver. Properly  applied,  that  is  to 
say,  with  powerful  traction  on  the 
hip  bent  at  a  right  angle,  the  effort 
will  often  be  rewarded  by  a  sudden 
snap,  which  indicates  that  the 
femoral  head  has  returned  to  its 
socket  (Fig.  252). 

Third  Movement:  External  Rota- 
tion with  Abduction. — Persisting  in 
the  traction,  the  resisting  muscles 
are  felt  to  yield.  Now  carry  out  the  final  maneuver,  which  should 
guide  the  head  over  the  rim  of  the  acetabulum  into  place.  Continue 
traction  to  some  extent,  but  rotate  the  thigh  outward  and  at  the 
same  time  abduct.  All  the  other  methods  proposed  are  but  modi- 
fications of  this  (Fig.  253). 


Fig.  250. — Backward  dislocation,  dorsum 
ilii;  shortening,  inversion.     (Moullin.) 


ISCHIATIC   DISLOCATION 


Diagnostic  points:  Adduction,  inward  rotation,  marked  flexion 
of  both  knee  and  hip  (Fig.  254). 


332 


INJURIES   TO   JOINTS 


Reduction. — By  the  same  method  as  the  dorsum  ihi.     Do  not  begin 
the  final  movement  of  abduction  and  external  rotation  too  soon. 


Fig.  251. — Dislocation  of  the  femur  upward  and  backward  in  a  child. 
The  arrow  points  to  the  acetabulum. 


SUBPUBIC    DISLOCATION 

Diagnostic  points:  Compared  with  the  ischiatic  an  opposite  con- 
dition of  affairs  exists — ^abduction,  external  rotation  and  extension. 
The  great  trochanter  cannot  be  located  (Fig.  255). 

Reduction. — 'Flexion  is  here  illusory,  and  equally  so,  blind  traction. 
Slightly  lifting  the  extended  limb,  abduct  it  as  far  as  possible;  while 


DISLOCATION    OF    THE   HIP 


33Z 


abducling  continue  to  lift.  The  head  rolls  down  toward  the  ob- 
turator foramen,  and  finally  the  thigh  stands  vertically.  Now 
adduct  and  rotate  inward. 


Fig.  252. — Reduction  of  the  hip.      Flexion  of  the  knee.      Gradual,  flexion  of 
the  hip  with  traction  on  thigh. 


OBTURATOR     DISLOCATION 


Diagnostic  points:  The  hip  is  flexed,  abducted,  and  rotated  out- 
ward (Fig.  256). 

Reduction. — Flexion  of  hip,  traction  on  flexed  thigh,  adduction, 
inward  rotation. 


334  INJURIES    TO   JOINTS 

DISLOCATION  OF  THE  KNEE 

This  accident  is  infrequent,  easy  of  diagnosis,  and  comparatively 
easy  to  reduce. 

General  anesthesia  is  frequently  necessary.  Two  assistants  are 
needed,  one  for  traction  on  the  leg  and  one  for  counter- traction  on  the 
thigh,  while  pressure  is  applied  at  the  joint. 


Fig.   253. — Reduction  of  hip.       Third  stage.     External  rotation. 
Hip  strongly  flexed. 

One  must  be  concerned  here  with  the  condition  of  the  blood 
vessels.  Suppose  there  is  no  pulse  at  the  ankle,  the  popliteal  space 
is  evidently  filled  with  blood.     Under  these  circumstances  apply  a 


DISLOCATION   OF   THE   KNEE 


335 


tourniquet,  and,  under  rigid  antisepsis,  open  up  the  space  by  a 
longitudinal  incision,  turn  out  the  clots,  ligate  the  torn  vessels. 
Remove  the  tourniquet,  complete  the  hemostasis,  and  sew  up  the 
wound.     The  limb  is  bandaged  in  cotton,  elevated,  and  kept  warm. 


Fig.  254. — Dislocation  of  hip 
backward  into  the  sciatic  notch. 
Leg  shortened,  foot  inverted. 
(Moullin.) 


Fig.  255. — Forward  dislocation: 
subpubic;  extension,  aversion. 
(Moullin.) 


Time  alone  can  tell  whether  or  not  the  circulation  will  be  restored 
and  gangrene  averted. 


DISLOCATION  OF  THE  SEMILUNAR  CARTILAGES 

This  is  an  injury  likely  to  be  forgotten  in  making  a  diagnosis  of 
disabilities  of  the  knee. 

The  internal  semilunar  cartilage  is  much  more  Ukely  to  be  in- 


33^ 


INJURIES    TO   JOINTS 


volved,  the  accident  usually  occurring  in  this  manner:  the  individual 
attempts  to  turn  suddenly  while  the  knee  is  flexed.  The  cartilage, 
either  as  a  whole  or,  more  often,  a  part,  projects  to  the  outside  or  in- 
side of  the  joint  circumference.  There  is  a  sudden  painful  locking 
of  the  joint. 

The  patient  himself  is  often  able  to  relieve  the  condition  by  a  little 
manipulation  of   the  joint,   combined  with  lateral    pressure.     The 

injury  is  a  serious  one,  functionally,  and 
demands  prolonged  rest,  in  the  hope  that 
union  may  occur.  An  elastic  silk  stocking 
for  the  knee  gives  support  and  tends  to 
prevent  recurrence  of  the  trouble,  but 
violent  movements  are  almost  sure  to 
bring  a  return.  If  asepsis  is  assured,  the 
joint  may  be  opened  and  the  cartilage 
sutured  to  the  tibia — an  operation  to  be 
advised  by  the  general  practitioner  and 
yet  scarcely  ever  necessary  to  be  under- 
taken by  him. 

DISLOCATION  OF  THE  PATELLA 

The  difficulties  in  correcting  the  dis- 
placement of  the  patella  are  various,  de- 
pending not  only  on  the  character  of  the 
dislocation,  but  also  on  the  condition  of 
the  ligaments  and  muscles. 

In  general,  there  is  one  method  of  treat- 
ment, viz.: 

Extend  the  leg  completely  and,  holding 

it  in  extension,   flex   the   thigh  to  a  right 

angle.      By  this  means  the  quadriceps  extensor,  in  whose  tendon  of 

insertion  the  patella  is  lodged,  is  relaxed,  permitting  the  bone  to  be 

manipulated  into  place. 

DISLOCATION  OF  THE  ANKLE  AND  TARSUS 

The  diagnosis  and  correction  of  these  injuries  are  more  especially 
matters  of  anatomy.     Whoever  has  clearly  in  mind  the  relations  of 


Pig. 

tion. 


;6. — Downward  disloca- 
Obturator.      (Moullin.) 


DISLOCATION   OF   THE   ANKLE 


337 


the  components  of  the  foot,  can  determine  the  character  of  the  disar- 
rangement with  the  minimum  difficulty. 

If  the  diagnosis  is  wrongly  made,  correct  reposition  is  lacking, 
and  in  consequence  there  persists  a  degree  of  deformity  and  loss  of 
function. 

One  must  begin  his  task  of  diagnosing  a  serious  injury  to  the  foot 
by  recalling  the  relations  of  the  malleoli  and  astragalus,  the  os  calcis, 
and  the  other  tarsal  bones,  to  each  other. 


Fig    257. — Backward  dislocation  of  ankle  with  fracture  of  the  tibia. 


Inspect  the  foot;  the  heel,  the  sole,  the  borders,  the  malleoli,  the 
tendo  achillis — and  compare  each  of  these,  point  for  point,  with  the 
sound  side.  Remember  that  the  line  of  the  tibial  crest,  prolonged, 
falls  on  the  second  toe. 

A  dislocation  of  the  ankle-joint  assumes  various  forms.  The  other 
bones  may  be  dislocated  from  the  astragalus,  which  retains  its  normal 
relation  to  the  malleoli.     There  may  be  solely  a  dislocation  of  the 


22 


338 


INJURIES    TO   JOINTS 


astragalus,  which  may  take  almost  any  position  imaginable.  Less 
often  one  finds  displacement  of  the  metatarsals  and  phalanges. 
There  may  be  a  fracture  of  the  fibula  (Fig.  257). 

It  is  scarcely  possible  to  indicate  an  exact  method  of  reducing 
such  luxations.  The  surgeon's  ingenuity  must  suggest  the  proper 
variations  of  traction  combined  with  pressure.     A  type  may  be  found 

in  backward  dislocations  of  the  ankle  (Fig. 

258). 

The  malleoli  are  carried  forward,  the 
heel  is  elongated,  the  foot  shortened. 
There  is  a  transverse  fold  in  front  of  the 
ankle,  ridged  vertically  by  the  stretched 
extensor  tendons. 

Reduction. — -The  patient's  foot  projects 
over  the  end  of  the  table,  an  assistant 
steadying  the  flexed  knee.  Grasp  the 
heel  with  one  hand  and  the  middle  of  the 
foot  with  the  other  (Fig.  259).  Make 
traction  at  first  to  reflex  the  opposing 
muscles  and  then  shove  the  foot  forward 
and  at  the  same  time  flex  it. 
After-treatment. — -The  injured  joint,   carefully  padded,  must  be 

fixed  by  a  plaster  splint.     After  eight  to  ten  days,  passive  motion 

and  massage  must  be  begun. 


Fig.     258. — Backward    disloca- 
tion of  ankle.     (Moullin.) 


COMPOUND  DISLOCATIONS 


These  are  accidents  always  to  be  dreaded,  and  yet  they  yield  ex- 
cellent results  under  antiseptic  methods. 

Before  you  is  a  joint  wide  open,  the  articular  surfaces  bare,  per- 
haps protruding,  and  immediately  you  think  of  resection  or  amputa- 
tion, and  yet  you  will  do  neither.  You  will  proceed  to  do  a  most 
careful  disinfection  and  to  secure  a  complete  reposition  and  immo- 
bilization.    The  one  chief  concern  is  disinfection. 

The  same  indications  for  treatment  are  present  as  in  compound 
fracture  into  joints  (see  page  283)  and  depend  upon  the  degree  of 
injury  to  the  soft  parts  and  whether  the  infection  is  or  is  not  obvious. 


COMPOUND  DISLOCATIONS  339 

The  skin  about  the  wound  is  prepared  as  for  a  surgical  operation, 
the  wound  is  thoroughly  flushed  out  with  normal  salt  solution,  foreign 
bodies  are  removed,  and  replacement  is  effected.  The  next  step  will 
vary,  depending  upon  the  degree  of  confidence  in  having  completely 
sterilized  the  joint  cavity.  If  the  effort  has  been  exacting  in  that 
regard,  tightly  suture  the  deep  layers  over  the  joint,  close  the  super- 
ficial layers  with  interrupted  sutures  and  apply  drainage. 

If  the  articular  structures  were  impregnated  with  dirt,  one  will 
still  fear  suppuration  despite  the  greatest  care  in  cleansing,  and  will 


Fig.  259. — -Reduction  of  dislocated  ankle.     The  assistant  steadies  the 
flexed  knee.     {Heath.) 

close  the  wound  less  firmly  and  provide  for  free  drainage.  Remov- 
ing as  many  bacteria  as  possible,  starving  those  that  remain  by  re- 
moving their  food  supply — -devitalized  tissue  and  blood  serum — -are 
the  principles  of  treatment;  cleansing  and  draining,  the  means;  heal- 
ing without  inflammation  or  suppuration,  the  end. 

Dressing  and  After-care. — ^Having  provided  for  drainage,  cover  the 
wound  with  sterile  gauze,  envelop  the  limb  in  absorbent  cotton  and 
immobilize  the  joint  with  a  plaster  splint. 

As  soon  as  the  soft  parts  are  healed  and  the  danger  of  infection  has 
passed,  begin  massage  of  the  muscles  and  slight  movement  of  the 
parts  daily. 

But  in  spite  of  careful  cleansing,  infection  may  develop.  On  the 
third  day,  perhaps,  a  chill  occurs,  the  fever  mounts  rapidly  and  there 
are  all  the  local  signs  of  inflammation  and  sepsis.     Do  not  temporize, 


340  INJURIES   TO   JOINTS 

but  immediately  open  the  wound,  douche  thoroughly  with  peroxide 
or  iodine  water  and  leave  the  wound  open.  Immobilize.  If  the 
temperature  does  not  fall  and  the  local  conditions  do  not  improve  in 
a  few  hours,  proceed  at  once  to  do  an  arthrotomy  (see  page  440). 

The  thorough  drainage  by  this  means  obtained  will  usually  control 
the  situation.  The  drainage  is  gradually  withdrawn,  and  will  not  be 
necessary  after  about  the  tenth  day.  If,  even  then,  the  swelling  and 
fever  do  not  subside,  there  is  nothing  left  to  prevent  a  general  in- 
fection but  immediate  amputation,  and  even  that  may  be  too  late. 

The  shoulder-joint  rarely  suffers  a  compound  dislocation.  Such  an 
injury  is  especially  serious  for  the  reason  that  there  are  so  many  com- 
plications; the  shoulder  muscles  are  torn,  the  axillary  vessels  and  the 
nerves  of  the  brachial  plexus  lacerated. 

It  must  be  treated  on  the  general  principles  enumerated  and  the 
result  is  often  surprisingly  good.  If  traumatic  aneurism  exists,  the 
pectoralis  muscles  must  be  divided,  the  space  exposed  and  the  vessels 
ligated. 

The  hip-joint  is  occasionally  the  site  of  a  compound  dislocation  and 
nearly  always  the  shock  is  fatal. 

Elbow. — This  is  a  comparatively  frequent  accident  and  is  treated 
on  the  general  principles  outlined.  If  the  injuries  are  severe,  a 
partial  excision  may  be  required  to  perfect  drainage  and  insure  a 
better  joint.  Amputation  will  be  indicated  only  in  old  age,  morbid 
constitutional  disability,  or  extreme  local  destruction. 

An  automobile  overturning  caught  the  driver  in  such  way  as  to 
produce  a  compound  dislocation  of  his  elbow\  He  was  brought  in  by 
the  ambulance,  with  a  tourniquet  on  the  arm. 

Under  a  general  anesthesia  the  wound  was  explored  after  cleansing 
with  tr.  iodine. 

The  end  of  the  humerus  protruded  through  one  ugly  ragged  rent. 
The  brachial  artery  was  torn,  the  ends  widely  separated.  The 
brachiahs  anticus  could  scarcely  be  identified  and  the  median  nerve 
stood  out  prominently,  stretched  over  the  projecting  bone. 

Reduction  was  accomplished,  the  torn  vessels  ligated,  the  tourni- 
quet removed  and  an  effort  made  to  suture  the  capsule. 

Next  the  torn  brachialis  anticus  and  the  group  of  muscles  attached 
to  the  internal  condyle  were  repaired  in  a  fashion,  with  chromic  gut; 


COMPOUND   DISLOCATION 


341 


the  bicipital  fascia  was  sutured  also  with  chromic  and  the  skin  with 
silkworm-gut  with  slight  drainage;  the  joint  was  fixed  in  flexion  with 
plaster  in  the  form  of  a  posterior  splint. 

On  account  of  the  ruptured  brachial  artery  gangrene  was  feared 
but  at  the  end  of  thirty-six  hours  a  slight  radial  pulse  was  felt.  There 
was  much  swelling  and  great  pain,  but  scarcely  any  rise  of  tem- 
perature. 


Fig.   260. — Fracture   and   compound   dislocation   at   the   wrist.     Hand  saved.      {Scudder.) 

Eventually  a  considerable  slough  occurred  in  the  wound,  but  with- 
out evidence  of  infection.  A  month  was  required  for  repair  of  the 
wound. 

Under  an  anesthetic  the  limb  was  gradually  extended  and  fixed  in 
that  position  for  a  while.  At  the  end  of  the  sixth  week  it  was  flexed 
again,  this  time  manipulated  quite  freely. 

The  whole  forearm  remained  very  painful  and  the- patient  was  un- 
able to  move  it.  He  insisted  on  amputation,  but  was  encouraged  to 
persevere  with  massage,  the  electric  current  and  hot  baths.  Some 
improvement  in  the  pain  was  secured  and  the  patient  began  to  work 
with  the  joint  himself.     From  that  time  on  the  joint  gradually  re- 


342  INJURIES    TO   JOINTS 

sumed  all  its  functions  and  at  the  end  of  sLx  months  he  was  driving 
his  Ford  as  swiftly  as  before. 

The  wrist  should  be  treated  conservatively.  A  loose  carpal  bone 
may  require  removal  or  partial  resection.  Amputation  will  be  re- 
quired if  heaUng  is  ob\'iously  out  of  the  question  (Fig  260). 

Compound  dislocations  of  the  knee-joint  are  very  rare.  If  con- 
servatism fails,  amputation  is  the  only  alternative. 

Ankle  and  Tarsus. — These  dislocations  are  frequent  and  require 
much  attention.  Antiseptic  foot  baths  ser\^e  an  excellent  purpose 
though  the  primary  cleansing  must  be  especially  vigorous.  The 
tarsal  bones  may  need  to  be  sutured,  to  be  retained  in  place.  Espe- 
cial care  must  be  taken  not  tomterfere  ^dth  the  circulation  (see  page 
288.  compound  fractures). 

CONTUSIONS  OF  THE  KNEE-JOINT 

These  are  so  frequent  as  to  call  for  a  special  word.  The  aim  is  to 
avoid  an  acute  synovitis,  which  may  become  suppurative.  In  milder 
cases,  rest  in  bed  -^ith  some  mild  liniment  and  light  massage  will 
be  sufficient,  and  the  pain  and  stiffness  will  rapidly  subside. 

In  the  severer  cases,  indicated  by  pain  and  swelling,  more  active 
measures  must  be  instituted. 

Wrap  the  joint  in  absorbent  cotton  and  apply  a  plaster  bandage  for 
two  or  three  days.  The  uniform  pressure  will  limit  the  effusion  and 
hasten  its  asbsorption.  After  that  you  may  begin  hot  sponging  and 
ver}'  gentle  passive  motion  with  massage,  applied  at  first  only  to  the 
muscles  moving  the  joint,  and  afterward,  as  the  tenderness  subsides, 
to  the  joint  itself. 

PUNCTURE  AND  STAB  WOUNDS  OF  THE  KNEE-JOINT 

The  treatment  will  depend  largely  on  the  instrument  which  in- 
flicted the  wound  and  the  appearance  of  the  wound.  If  the  wound 
is  clean-cut,  and  the  instrument  presumably  non-septic,  content 
yourself  -v^-ith  sterilizing  the  field  of  the  wound,  enveloping  the  knee  in 
an  antiseptic  compress  and  putting  the  joint  at  rest,  preferably  in  a 
plaster  splint.  You  will  anxiously  watch  the  temperature.  If  it 
does  not  rise  within  three  or  four  days,  one  may  cease  to  fear  infec- 
tion, and  such  sweUing  as  appears  is  not  significant. 


SPRAINS  343 

It  is  quite  dififerent  when  the  temperature  begins  to  rise  and  the 
local  symptoms  gradually  increase,  or  if  the  wound  is  seen  after  some 
days  of  neglect  and  the  symptoms  of  infection  are  fully  developed. 

Under  these  circumstances,  there  must  be  no  delay.  Immediate 
operation  is  imperative;  it  is  indicated  to  do  an  arthrotomy,  disinfect 
and  drain  (see  page  440). 

This  treatment,  early  and  properly  applied,  will  save  the  joint. 
As  infection  subsides,  the  drainage  is  gradually  withdrawn. 

There  are  cases,  however,  in  which,  unfortunately,  even  these 
strenuous  measures  fail.  In  spite  of  immediate  recognition  of  the 
urgency,  and  immediate  action,  laying  open  the  joint  with  the  ut- 
most freedom,  followed  by  repeated  irrigations — 'in  spite  of  the  ut- 
most endeavor,  the  symptoms  of  grave  general  infection  persist  and 
it  is  necessary  to  amputate.  This  may  save  the  patient's  life — more 
often  it  will  not. 

EXTENSIVE  INCISED  OR  LACERATED  WOUNDS  OF 
THE  KNEE-JOINT 

In  these  cases,  it  is  never  sufficient  merely  to  cleanse  the  skin  and 
seal  the  wound  with  antiseptic  dressings.  The  wound  must  be  en- 
larged, thoroughly  cleansed,  and  the  joint  cavity  irrigated  with 
sterile  water  or  normal  salt  solution  and  wiped  dry  with  sterile  gauze. 

After  the  complete  disinfection,  the  wound  in  the  capsule  is  sutured 
and,  perhaps,  also  the  skin.  More  frequently,  however,  one  will 
feel  safer  to  leave  drainage  in  the  skin  wound.  The  joint  is  immobil- 
ized, and  if  everything  goes  well,  the  drainage-tube  is  removed  after 
forty-eight  hours. 

SPRAINS 

In  general,  these  conditions  are  to  be  treated  by  firm  bandaging  for 
two  or  three  days,  to  limit  the  swelling  and  hasten  the  absorption  of 
the  effusion;  and  then  massage  and  sHght  passive  motion  are  begun. 
It  is  better  to  give  the  joint  functional  rest  until  at  least  the  greater 
part  of  the  pain  has  subsided. 

The  ankle-joint  is  more  frequently  sprained  than  any  other,  partly 
on  account  of  its  construction  and  partly  on  account  of  its  function. 
The  weight  of  the  body  falls  on  the  insecurely  poised  foot  and  the 


344  INJURIES    TO   JOINTS 

ankle  gives  way  under  the  load.  The  ankle  usually  bends  outward 
and  the  external  lateral  ligaments  are  subjected  to  great  strain. 
They  are  undoubtedly  often  lacerated  or  the  capsular  ligament  may 
be  torn.  The  pain  in  the  severe  cases  is  immediate  and  intense;  the 
patient  may  faint.  If  the  joint  is  continued  in  use,  the  swelling  is 
aggravated,  but  in  any  event  swelling  rapidly  ensues. 

Morphine  may  be  necessary  to  relieve  the  pain.  If  seen  at  once, 
the  ankle  is  immobilized  in  plaster  of  Paris  for  a  few  days,  or  band- 
aged tightly  with  a  flannel  or  rubber  bandage,  or  strapped  with  adhe- 
sive plaster,  after  which  massage  and  passive  motion  are  employed. 
The  patient  should  walk  with  crutches  at  first.  The  joint  will  be 
stronger  than  if  it  was  used  before  the  pain  and  swelling  had  subsided, 
although  excellent  authorities  advise  walking  from  the  first. 

If  adhesive  strips  are  used,  in  order  to  avoid  circular  constriction, 
apply  them  in  this  manner:  cut  the  adhesive  strips  J^  inch  wide 
and  in  two  lengths,  12  and  18  inches. 

(i)  Begin  with  one  of  the  long  strips  in  front  of  the  big  toe,  carry 
the  strip  back  around  the  heel,  keeping  just  above  the  contour  of  the 
sole,  and  bring  the  strip  back  across  the  dorsum  of  the  foot  to  the 
starting-point.  Overlap  with  this  a  similar  strip.  Both  should  be 
tightly  drawn. 

(2)  Begin  with  one  of  the  shorter  pieces  above  the  ankle  and  carry 
it  under  the  heel  to  the  opposite  side. 

The  subsequent  strips  are  applied  alternately  in  this  fashion,  each 
overlapping  the  one  preceding,  until  the  foot  is  practically  covered. 
The  whole  is  then  enclosed  in  an  ordinary  roller  bandage  and  the 
foot  kept  quiet.  After  two  or  three  days,  the  patient  may  begin  to 
move  around  a  little,  but  the  dressing  must  be  left  on  till  the  pain  and 
swelHng  have  subsided.  It  may  be  reinforced  by  additional  strips 
placed  over  the  loose  ones. 

The  manner  of  giving  massage  is  also  important.  In  the  case  of  a 
tender  joint,  begin  by  gently  stroking  the  healthy  tissues  just  above 
the  joint  in  the  direction  of  the- blood  and  lymph  currents,  and  gradu- 
ally approach  the  joint.  The  movements  are  gradually  made  more 
vigorous,  using  the  palmar  surface  of  the  hand.  After  a  few  minutes 
of  this  work,  the  joint  will  usually  permit  a  direct  manipulation  and 
finally  slight  passive  movement  is  begun. 


RUPTURE    OF   THE   CRUCIAL   LIGAMENTS  345 

RUPTURE  OF  THE  CRUCIAL  LIGAMENT  OF  THE  KNEE 

An  injury  to  the  knee-joint  often  diagnosed  as  sprain,  is  rupture  of 
the  crucial  Hgament  of  the  joint.  This  injury  happens  when  violence 
is  applied  to  the  flexed  joint  at  which  time  the  anterior  ligament  is 
very  tense. 


Fig.   261.— Rupture  of  the  crucial  ligament  due  to  lateral  blow  on  flexed  knee.     The  X-ray 
usually  shows  a  portion  of  the  tibial  spine  wrenched  of=f. 

.  Turning  suddenly  on  the  flexed  knee  may  produce  the  same  result. 
The  pain  and  disability  are  out  of  all  proportion  to  the  apparent  in- 
jury, but  the  swelling  is  not  extreme.  The  X-ray  will  usually  in- 
dicate the  nature  of  the  trouble  not  because  the  ligaments  cast  a 


346       •  INJURIES    TO   JOINTS 

shadow,  but  because  some  fragments  of  the  bony  attachments  are 
avulsed.  In  fact  in  some  cases  ''fracture  of  the  tibial  spine"  is  the 
better  diagnosis  (Fig.  261). 

Prolonged  fixation  in  plaster  is  the  proper  treatment.  Massage, 
manipulation,  or  limited  use  should  not  begin  until  repair  is  prac- 
tically complete,  which  will  require  at  least  two  months;  and  even 
after  that,  a  splint  permitting  restricted  motion  only  may  need  to 
be  worn. 


CHAPTER  XIX 
INJURY  AND  REPAIR  OF  TENDONS 

There  are  three  kinds  of  injuries  to  tendons  which  it  is  practical  to 
consider  as  emergencies:  dislocated  tendons,  subcutaneous  rupture, 
and  divided  tendons. 

Dislocation  of  Tendons. — 'Dislocation  is  not  a  frequent  injury,  and 
yet  it  occurs  and  is  to  be  considered  as  a  possibility  in  making  a  diag- 
nosis of  disturbances  of  function  after  certain  joint  accidents.  Every 
sprain  should  be  examined  with  this  point  in  view. 

The  tendons  most  frequently  dislocated  are  those  of  the  peronei 
muscles,  especially  the  hrevis.  Following  a  severe  wrench  of  the 
ankle,  it  is  torn  out  of  its  sheath  behind  the  external  malleolus  and 
carried  forward  onto  the  malleolus,  where  it  can  be  felt  and  moved. 

It  is  easily  replaced,  but  it  is  with  more  difficulty  retained.  The 
ankle  must  be  immobilized  at  a  right  angle  to  relax  the  calcaneo-fibu- 
lar  ligament,  and  the  tendon  retained  by  pressure  until  the  ruptured 
tendon  sheath  or  lateral  ligament  is  healed,  which  will  require  about 
four  weeks.  It  will  sometimes  be  necessary  to  expose  the  tendon  and 
repair  the  rupture  tissues. 

The  long  tendon  of  the  biceps  may  be  wrenched  from  its  groove  in 
the  humerus  and  the  loss  of  function  and  prominence  of  the  head  of 
the  humerus  may  suggest  dislocation  of  the  humerus.  As  a  rule,  the 
tendon  is  easily  replaced  by  a  little  manipulation,  but  the  useful- 
ness of  the  arm  will  be  impaired  for  a  long  time. 

The  other  tendons  of  ankle  and  wrist  occasionally  may  suffer  simi- 
larly, but  not  seriously. 

Subcutaneous  Rupture. — Subcutaneous  rupture  is  especially  likely 
to  occur  with  the  tendon  of  the  quadriceps  extensor  or  triceps  cubiti 
or  the  tendo  achilKs.     A  sudden  violent  effort  is  the  usual  cause. 

The  pain,  the  loss  of  function,  the  gap  between  the  ends  of  the  rup- 
tured tendon,  and  the  history  of  sudden  muscular  contraction  point 
to  the  nature  of  the  injury. 

347 


348 


INJITRY   AND   REPAIR    OF    TENDONS 


There  is  only  one  logical  treatment,  viz. :  by  an  incision  to  expose 
the  tendon  at  once  and  by  some  of  the  methods  shortly  to  be  de- 
scribed, reunite  the  parts  by  suture.  It  is  the  duty  of  the  doctor  to 
insist  on  nothing  less  (Fig.  262).  But  it  must  be  remembered  that 
the  synovial  sac  is  peculiarly  susceptible  to  infection  and  the  skin 
over  the  patella  difficult  to  sterilize. 


Fig.  262. — Repair  of  ruptured  tendon  of  quadriceps  extensor  femoris.  d,  tendon;  c, 
basting  stitches;  b.  sutures  uniting  posterior  edges;  a,  sutures  uniting  anterior  edges  of 
ruptured  tendon.      (Bryant.) 


If  this  procedure  is  not  followed,  it  remains  only  by  position,  rest, 
and  massage  to  favor  repair,  which,  at  the  best,  will  be  uncertain 
and  slow. 

The  position  must  be  such  as  to  relax  the  muscle,  the  limb  must  be 
immobilized,  and  after  the  first  few  days  massage  must  be  begun 
and  carried  out  systematically. 


INJURY   OF   TENDONS    AT   THE    WRIST 


349 


Fig.  263. — Incised  wound  of  back  of  wrist.     Divided  tendons  exposed.     iVeau.) 


Fig.  264. — "Expression"  of  retracted  end  of  divided  tendon  by  forced  flexion  and  com- 

pression  of  forearm.     {Veau.) 


350 


INJURY   AND   REPAIR   OF   TENDONS 


The  history  of  a  case  reported  by  Gage,  of  Worcester,  Mass.,  is 
tv^ical.  A  man,  fifty-seven  years  old,  slipped  and  fell  with  his  left 
knee  doubled  under  him.  He  could  not  lift  his  leg  from  the  ground. 
Examination  an  hour  later  showed  a  gap  6  cm.  wide  between  the 
upper  border  of  the  patella  and  the  retracted  edge  of  the  quadriceps 
tendon. 


Fig.   265. — Exposure  of  tendons  by  enlarging  wound  in  aponeurosis.     Suturing 

tendons.      (Veau.) 


Operation. — A  transverse  incision  was  made  across  the  front  of  the 
knee  and  the  ruptured  tendon  exposed.  The  rupture  was  complete 
except  for  a  few^  fibers  on  the  outer  edge.  The  joint  was  exposed, 
the  clots  wiped  out.  The  edges  of  the  tendon  were  then  carefully 
coapted  with  interrupted  catgut  sutures.  The  leg  was  put  up  in 
plaster-of-Paris  splint  for  seven  weeks.  After  that  it  was  massaged 
daily  and  the  splint  definitely  removed  at  the  end  of  twelve  weeks. 
The  leg  became  as  strong  and  flexible  as  before  the  accident. 


SUTURE    OF    TENDONS 


351 


Divided  Tendons. — These  are  found  frequently,  especially  at  the 

wrist.     They  must  be  immediately  sutured  for  then 

it  is  relatively  easy.     Later  they  retract  or  acquire 

adhesions  and  it  is  difficult  to  approximate  the  two 

ends,    and    one    must    have    recourse    to    special 

maneuvers. 

Use  No.  I  or  No.  2  silk  or  chromicized  catgut. 

A  small  curved  needle  or  a  straight  sewing  needle 

will  serve. 

Begin  by  carefully  disinfecting  the  wound  and 

securing  complete  hemostasis.     The  low^er  ends  of 

the  divided  tendons  will  usually  be  found  near  the 

lower  lip  of  the  wound  (Fig.  263).     Identify  each 

and  count  them  to  be  sure  none  have  been  over- 
looked.    At  the  same  time,  see  if  a  nerve  has  been 

divided.     Look  for  the  others  of  the  divided  ends. 

If  they  are  not  in  sight,  do  not  reach  blindly  for 

them  with  forceps,  but  attempt  to  bring  them  into 

view  by  '' expression,"  and  if  this  fails,  boldly  en- 
large the  wound. 

Expression. — Direct  the  assistant  to  grasp  the 

member  above  the  wound  wdth  both  hands  and  the 

pressure  may  force  the  tendons  into  view.     If  the 

extensor  tendons  are  involved,  employ  forced  flexion 

with  the  pressure.     These  muscular  groups  are  more  or  less  unified 

and  the  undivided  tendons  put 
on  the  stretch  help  to  drag 
the  divided  tendons  into  view 
(Fig.  264). 

If  this  method  does  not  suc- 
ceed, apply  a  roller  bandage, 
beginning  at  the  elbow- joint  in 
the  case  of  the  upper  extrem- 
ity; at  the  knee  in  the  case  of 
the  leg  or  foot,  and  carry  it 
down  to  within  an  inch  of  the 

wound.     If  this,  too,  fails,  make  difree  incision  observing  this  point; 


C.I)»B«'*« 


Fig.  266. — One 
method  of  suturing 
tendon  of  medium 
size.     {Veau.) 


Fig. 


267. — Method  of  introducing  suture  for 
divided  tendon.     (Marsee.) 


352 


INJURY   AND   REPAIR    OF    TENDONS 


Fig.  268. — Suture    of    tendons    completed.     Repair    of    aponeurosis.     The    aponeurosis 
should  not  be  divided  directly  over  the  tendons  else  adhesions  may  occur.     (Veau.)^ 


Fig.  269. — Suture  of  a  flattened 
tendon.     (Veau.) 


\  aX 


Fig.  270. — Suture  of  a  lacer- 
ated tendon.     {Veau.) 


SUTURES    OF    TENDONS  353 

do  not  make  the  incision  directly  over  the  tendon  for  it  may  later 
acquire  adhesions  to  the  scar  tissue,  interfering  with  its  free  move- 
ment. Generally  with  a  little  patience  the  tendon  is  found.  It 
is  often  practical  after  incising  the  skin  to  make  a  diagonal  incision 
of  the  deep  fascia  or  two  incisions  at  a  right  angle,  creating  a 
flap  which  may  be  dissected  up  and  the  tendon  group  well  exposed 
(Fig.  265). 

Suture  of  the  Tendon. — (A)  The  tendon  is  round,  as  at  the  level 
of  the  wrist-joint.  Seize  the  tendon  with  a  dissecting  forceps,  being 
careful  not  to  bruise  it.  Pass  a  suture  through  the  whole  thickness 
I4  inch  from  the  end  (Fig.  266),  entering  the  superficial  surface 
and  emerging  on  the  deep  surface  of  the  segment  and  carrying  it 
then  to  the  other  part;  entering  the  deep  surface  and 
emerging  on  the  superficial  surface.  The  ends  of  the 
divided  tendon  are  then  coapted  and  the  suture  tied. 

The  suture  may  be  passed  laterally  instead  of  antero- 
posteriorly.  If  the  ends  of  the  tendon  come  together 
well,  a  suture  may  be  entered  ^  inch  from  the  divided 
end  and  passed  obliquely  in  such  a  manner  that  it 
emerges  from  the  cut  surface  and  then  is  passed  into 
the  cut  surface  of  the  opposite  end  and  emerges  sym- 
metrically with  the  original  point  of  entrance.  Marsee 
advises  passing  a  separate  suture  three  times  through 
the  tendon,  tying  the  corresponding  ends  (Fig.  267). 

Repair  the  wound  in  the  deep  fascia  by  a  continuous 
suture,  being  assured  once  more  that  no  nerve  is  divided 

(B)  The  tendon  is  flattened.  In  this  case,  the  ends  Method  of 
must  overlap.     Make  a  latero-lateral  anastomosis;  pass    elongating  a 

tendon. 

the  suture  through  the  lower  end  from  before  backward, 
beginning  near  one  border.     Next  pass  the  suture  through  the  upper 
end  from  before  backward  and  again  from  behind  forward.     Finally 
pass  the  suture  from  behind  forward  through  the  lower  end.     When 
the  suture  is  ready  to  tie,  the  lower  end  overlaps  the  upper  (Fig.  269). 

(C)  The  tendon  is  shattered  or  lacerated.  In  this  case  before  sutur- 
ing tie  a  firm  ligature  around  either  end,  which  will  prevent  the 
suture  from  pulling  out  (Fig.  270). 

23 


354 


INJURY    AND   REPAIR    OF    TENDONS 


Fig.  272. — Suture  by  double  anastomosis 
when  the  two  ends  of  the  divided  tendon 
cannot  be  brought  in  contact.      (Veau.) 


Fig.  273. — The  upper  end  cannot  be 
found.  Suture  to  adjoining  tendon. 
( \'eau.) 


Fig.   274. — The  long  extensor  of  the  thumb  divided,  the  upper  end  lost.     The  adjoining 
tendon  is  split  and  one  segment  sutured  to  long  extensor.      {Schwartz.) 


SUTURE    OF    TENDONS 


355 


(D)  The  tendon  is  voluminous.  In  this  case  it  is  better  to  vary  the 
method  a  little.  Pass  the  transverse  suture  as  in  Fig.  266.  Before 
tying  the  suture,  the  posterior  lips  are  drawn  together  as  neatly  as 
possible.  When  these  sutures  are  all  tied,  finally  suture  the  anterior 
lips  together.  Over  all  suture  the  deep  fascia.  The  transverse 
suture  must  be  strong,  No.  3  silk  for  example,  though  the  others 
may  be  finer. 

(E)  The  ends  cannot  he  approximated.  This  will  not  happen  ex- 
cept in  the  neglected  cases.     Two  procedures  are  practical. 

(i)  The  space  may  be  bridged  by  sutures,  which  will  favor  re- 
union by  scar  tissue.  Begin  by  ligating  both  ends  (Fig.  270)  and 
then  pass  three  to  six  sutures  as  the  one  is  passed  in  the  figure. 

(2)  The  space  may  be  bridged  by  splitting  the  upper  tendon  in 
the  manner  indicated  in  Fig.  271.     Before  the  tendon  is  split,  it 


Fig.   275. — Plaster  splint  applied  to  maintain  flexion. 

must  be  ligated  near  its  end.  In  the  case  of  the  tendo  achillis,  it  may 
be  lengthened  by  making  several  half  cross  sections  at  different  levels, 
first  one  side  and  then  the  other. 

(3)  The  two  ends  may  be  sutured  to  a  neighboring  tendon  (Fig. 
272). 

(F)  The  upper  portion  of  the  divided  tendon  cannot  he  found.  In 
this  case,  buttonhole  a  neighboring  tendon,  selecting  one  nearest 
resembling  in  function  the  divided  one.  Into  the  sHt  pass  the  end 
of  the  divided  tendon  and  fasten  with  one  or  two  sutures.  The 
divided  tendon  should  be  slightly  on  the  stretch  when  the  suturing 
is  completed  (Fig.  273). 


356  INJURY  AND  REPAIR  OF  TENDONS 

The  healthy  tendon  may  be  spht  and  the  separated  portion  sutured 
to  the  divided  tendon  (Fig.  274). 

Drainage. — -Drainage  is  necessary  if  the  wound  was  accidental.  A 
small  drainage-tube  is  left  beneath  the  skin.  The  fascia  has  been 
completely  closed.     Apply  a  dry  antiseptic  and  absorbent  dressing. 

Immobilize  the  part  in  a  position,  flexion  or  extension,  to  relax  the 
tendons.  If  necessary,  apply  a  plaster  bandage  over  the  dressing. 
An  excellent  splint  is  made  by  taking  a  plaster  roller,  properly  soaked, 
and  folding  it  back  and  forth,  pressing  the  folds  carefully  together 
until  a  five-  to  eight-ply  splint  of  proper  wddth  and  length  is  made. 
This  is  slightly  padded,  bandaged  in  place  and  held  at  the  necessary 
degree  of  flexion  till  the  plaster  hardens  (Fig.  275). 


CHAPTER  XX 
INJURY  AND  REPAIR  OF  NERVES 

THE   REPAIR   OF   DIVIDED   NERVES 

It  is  imperative  to  suture  a  divided  nerve  as  soon  as  the  condition 
is  recognized.  If  the  repair  is  made  at  once  it  is  more  easily  done  than 
the  suture  of  tendons,  for  the  ends  are  not  so  widely  separated;  but, 
on  the  other  hand,  it  is  more  delicate  work,  for  the  trunks  are  smaller. 

Do  not  handle  these  tissues  roughly  and,  above  all,  do  not  cleanse  the 
wound  with  strong  antiseptics,  such  as  bichloride  and  carbolic  acid. 

Remember  that  the  upper  part  of  the 
nerve  retains  its  sensitiveness  and  in  it  are 
the  essentials  of  repair.  The  lower  seg- 
ment degenerates  if  repair  is  neglected. 

It  is  usually  necessary  to  freshen  the 
ends,  but  one  must  be  very  sparing  of  the 
tissues,  removing  less  than  a  millimeter 
from  each  extremity,  using  fine  sharp 
scissors.  It  is  better  to  make  the  sec- 
tion oblique  (Fig.  276). 

Pass  a  silk  (No.  o)  suture  or  a  small 
catgut  with  a  round  needle  through  the 
whole  thickness,  as  in  the  case  of  a  round 
tendon  (Fig.  277),  draw  the  ends  together 
and  complete  the  repair  by  suturing  the 
lips,  passing  the  suture  through  the 
nerve  sheath  only  (Fig.  278).  Adjust  the  ends  exactly  and  always 
where  possible  make  the  suture  an  end-to-end  one. 

Repair  the  various  layers  of  fascia  with  great  care,  so  that  the 
sutured  nerve  may  be  isolated  and  removed  from  the  sources  of 
infection.     Employ  drainage  in  suturing  the  skin. 

357 


/' 


Fig.  276. — Ob- 
lique section  of 
the  nerve  ends. 


Fig.  277. — 
Through  and 
through  suture 
of  nerve. 

(Veau.) 


358 


INJURY   AND   REPAIR   OF   NERVES 


For  the  rest,  the  treatment  is  the  same  as  for  any  other  wound. 

Secondary  Suture. — It  may  be  found  necessary 
to  suture  a  nerve  some  time  after  the  injury,  and 
this  operation  will  present  difficulties.  The  ends 
may  be  separated  or  they  may  be  imbedded  in 
scar  tissue. 

A  knob  often  forms  on  the  proximal  stump. 
In  such  a  case,  freshen  the  ends  and  pass  the 
suture  in  the  manner  pictured  (Fig.   279). 

If  the  two  ends  are  attached  by  a  fibrous  cord, 
split  the  scar  tissue  longitudinally  (Fig.  280),  and 
transform  the  longitudinal  fissure  into  a  transverse 
one  and  suture  (Fig.  281).  If  the  ends  cannot  be 
approximated  or  bridged  they  may  be  sutured  at 
different  levels  to  a  neighboring  nerve  in  the 
manner  described  under  Repair  of  Tendons. 

Warn  the  patient  that  it  may  be  a  long  time 
before  function  is  even  partially  restored.  In  the 
meantime,  muscular  atrophy  must  be  prevented 
of    nerve    through    by  persistcnt  use  of  electricity,  and  massage. 

the  sheath.     {Heath.) 


Fig.  278. — Suture 


CONTUSION   AND   COMPRESSION   OF   NERVES 


These  injuries  to  nerves  are  by  no 
means  infrequent,  following  blows,  gun- 
shot wounds,  machinery  accidents,  frac- 
tures, and  dislocations. 

The  symptoms  vary  from  slight  ting- 
ling to  complete  loss  of  function.  The 
loss  of  function  is  often  a  later  de- 
velopment, due  to  a  neuritis  following 
the  contusion,  and  is  accompanied  by 
neuralgia,  muscular  palsy  and  trophic 
alterations  corresponding  to  the  distri- 
bution of  the  nerve. 

Treatment. — -The  immediate  indica- 
tions are  to   restore  the  parts  to  their  normal  condition  as  much 


Fig.     279. — Secondary     suture. 
Method  of  coaptation.    (FeaM.) 


INJURY   TO   THE   FACIAL   NERVE 


359 


as  possible,  and  to  relieve  the  pain  by  hypodermic  injections  of 
morphine  or  by  phenacetine  and  codeine.  The  nerve  must  be  put 
at  rest  by  immobilizing  the  limb.  Later,  alteratives,  electricity, 
and  massage  are  useful. 


INJURIES  TO  INDIVIDUAL  NERVES 

Facial  Nerve. — -The  facial  is  more  frequently  injured  than  any 
other  cranial  nerve:  in  fracture  of  the  base  of  the  skull;  in  the  mas- 
toid operation  as  it  passes 
through  the  temporal  bone; 
by  shots  and  blows  at  its 
exit  from  the  styloid  fora- 
men. Depending  upon  the 
distance  of  the  lesion  from 
the  central  origin  of  the 
nerve,  there  occur  paralysis 
of  the  muscles  of  expression, 
disturbance  of  salivary  secre- 
tion and  the  sense  of  taste, 
and  paralysis  of  the  palatal 
muscles.  Injury  to  the 
facial  nerve  is  often  accom- 
panied by  injury  to  the  ab- 
ducens  and  auditory  nerves. 

To  Expose  the  Facial 
Nerve. — -The  incision  begins 
behind  the  external  auditory 
meatus  and  extends  down- 
ward and  forward  to  the 
angle  of  the  lower  jaw. 

Divide  the  integument,  superficial  fascia  and  the  first  layer  of  the 
deep  fascia.  This  exposes  the  parotid  gland,  the  sterno-cleido- 
mastoid  and  the  mastoid  process.  The  posterior  auricular  nerves 
and  the  vessels  are  to  be  avoided.  Carefully  dissect  and  draw 
forward  the  part  of  the  gland  exposed  and  the  posterior  belly  of 


Fig.  280.  Fig.  281. 

The  two  ends  of  the  nerve  are  connected  by  a 
fibrous  cord  which  is  split  longitudinally  and  su- 
tured as  indicated.      {Veau.) 


360  INJURY   AND   REPAIR   OF   NERVES 

the  digastric  appears,  just  above  which  the  nerve  lies  upon  the 
styloid  process. 

Optic  Nerve. — -The  optic  nerves  are  injured  most  frequently  in  con- 
nection with  fracture  of  the  base  of  the  skull  involving  the  anterior 
fossa,  and  especially  when  the  fissure  involves  the  optic  foramen 
for  there  the  nerve  is  firmly  attached  to  the  bone. 

As  a  consequence  of  such  injuries,  there  maybe  compression,  lacera- 
tion, or  extravasation  into  the  nerve  sheath.  As  a  result  of  these  in- 
juries, there  are  disturbances  of  vision  of  various  degrees.  In  ob- 
scure trauma  of  the  brain,  the  ophthalmoscopic  examination  of  the 
fundus  of  the  retina  should  never  be  Jieglected  as  a  means  of  diagnosis. 

Motor  Oculi  Nerve. — -The  motor  oculi  nerve  may  be  injured  by 
wounds  penetrating  the  orbit  and  by  fractures  of  the  base.  Its  func- 
tion may  be  disturbed  by  pressure  following  the  rupture  of  the  middle 
meningeal  artery  and  often  the  only  indication  of  this  disturbance  is 
a  dilated  pupil  and  drooping  of  the  eyelid. 

Patheticus  and  Abducens. — ^These  nerves  are  often  injured  along 
with  the  third,  producing  loss  of  rotation  and  abduction  of  the  eye  ball. 

Fifth  Nerve. — The  fifth  nerve  is  rarely  injured  alone,  but  injury  of 
single  branches  may  occur. 

''The  usual  consequence  of  anesthesia  of  the  trigeminals  following 
cranial  injury  is  so-called  keratitis  neuroparalytica." 

Auditory  Nerve. — -The  auditory  nerve  is  rarely  injured  without 
other  serious  lesions,  and  since  traumatic  disturbances  of  hearing 
may  be  due  to  injury  to  the  labyrinth  or  tympanum  also,  a  diagnosis 
of  injury  to  the  nerve  trunk  must  be  uncertain. 

The  pneumogastric  may  be  divided  or  contused  by  bullet  or  stab 
wounds  in  the  neck.  The  injury  is  not  necessarily  fatal,  but  may  be 
followed  by  difficulty  in  respiration  and  deglutition  or  by  pneumonia. 
When  the  symptoms  point  to  injury  an  effort  should  be  made  to  re- 
pair it.  It  is  reached  by  the  same  operation  as  that  for  ligation  of  the 
common  carotid. 

The  phrenic  when  divided  gives  rise  to  disturbances  of  the  func- 
tions of  the  diaphragm,  cough,  difficult  respiration. 

The- recurrent  laryngeal  when  divided  gives  rise  to  hoarseness  and 
aphonia.  If  injured,  an  attempt  should  be  made  at  repair.  Laryn- 
geal spasm  may  require  a  tracheotomy. 


REPAIR    OF    MEDIAN   NERVE  36 1 

Median  Nerve. —  The  median  nerve  is  likely  to  be  divided  by  stab- 
or  gunshot  wounds  and  may  be  exposed  in  any  part  of  its  course. 

Injury  to  the  median  nerve  results  in  impaired  flexion  of  the  hand 
and  fingers  and  movements  of  the  thumb. 

To  Expose  the  Median  Nerve. — ^(A)  In  the  middle  third  of  the  arm 
(Fig.  282):  Place  the  patient  on  the  back  with  arms  abducted  to  a 
right  angle,  the  operator  standing  to  the  inner  side  of  the  arm. 

With  the  two  hands  define  the  biceps  muscle.  Along  the  inner 
border  of  the  muscle,  following  the  known  line  of  the  nerve  (from  the 


Fig.   282. — Exposure  of  the  median  nerve  in  the  middle  third  of  the  arm.      B.   Biceps. 
M.  N.  Median  nerve.      B.  A.  Brachial  artery.      {Schwartz.) 

middle  of  the  axilla  to  the  middle  of  the  bend  of  the  elbow)  make  an 
incision  2  or  3  inches  long,  dividing  the  skin  and  connective 
tissue.  Divide  the  deep  fascia  over  the  biceps  and  open  the  sheath 
of  the  muscle.  Isolate  the  border  of  the  muscle  and  with  the  retrac- 
tor draw  it  gently  aside.  Do  not  use  force  or  the  nerve  also  will  be 
displaced  or  the  musculo-cutaneous  may  be  exposed  instead  of  the 
median. 

Now  incise  the  deep  layer  of  the  muscle  sheath  exactly  in  the  iine 
that  was  occupied  by  the  border  of  the  muscle  and  the  nerve  is  ex- 
posed lying  a  little  to  the  inside  of  the  vessels. 

(B)  At  bend  of  elbow  (see  Brachial  Artery). 

(C)  In  the  upper  third  of  the  forearm  (Fig.  283) :  The  incision  begins 


362 


INJURY   AND   REPAIR   OF   NERVES 


a  little  below  the  bend  of  the  elbow,  is  2  or  3  inches  in  length, 
and  follows  the  line  of  the  nerve,  which  hes  in  the  middle  hne  from 
the  elbow  to  the  wrist.  Di\ade  the  skin  and  ligate  the  two  superficial 
veins.  Under  the  deep  fascia  define  the  external  border  of  the  pro- 
nator radii  teres  and  over  this  border  incise  the  aponeurosis  and  re- 
tract the  muscle. 

The  nerve  is  immediately  exposed,  together  with  the  ulnar  artery, 
which  crosses  beneath  it,  running  obliquely  toward  the  inner  border 
of  the  forearm. 


W 


Med.X 


P.R.T. 


Fig.   284. — Exposure  of  the  median  nerve 
at  the  wrist.      {Schwartz.) 


Fig.  283. — Exposure  of  the  median  nerve 
just  below  the  elbow.  The  pronator  radii 
teres  (p.  r.  t.)  drawn  inward  exposing  the 
median  nerv'e  (m.  n.).  the  ulnar  artery_  (u. 
art.)  being  at  outer  side.     {Schwartz.) 


(D)  At  the  ivrist  (Fig.  284).  Make  an  incision  2  inches  in  length 
in  the  middle  line,  the  middle  of  the  incision  corresponding  to  the 
crease  of  the  wrist.  Divide  first  the  skin  and  the  fascia  and  then,  very 
carefully,  the  anterior  annular  ligament,  guarding  the  synovial  sheath 
of  "the  flexor  tendons.  Retract  the  lips  of  the  wound,  and  the  nerve 
is  exposed,  easily  distinguishable  from  the  adjacent  tendons  by  its 
fibrillated  appearance. 

The  Ulnar  Nerve.^The  ulnar  nerve  may  be  divided  anywhere 
along  its  course,   but  is  more  likely  to  be  contused  in  the   ulnar 


REPAIR    OF    ULNAR   NERVE 


363 


groove.  There  also  il  may  dislocated  by  forcible  flexion  of  the 
forearm.  The  loss  of  function  of  this  nerve  results  in  inability  to 
extend  the  distal  phalanges,  to  adduct  the  fingers  and  to  flex  the  little 
finger.  Eventually  the  ^Ulaw  hand^'  appears  as  a  result  of  atrophy 
of  the  muscles. 

To  Expose  the  Ulnar  Nerve. — (A)  In  the  arm:  Make  an  incision 
2  or  3  inches  in  length  along  the  line  of  the  nerve,  which  ex- 
tends from  the  middle  of  the  axilla  to  the  internal  condyle.  Divide 
the  skin  and  superficial  and  deep  fascia.  The  brachial  artery  is  about 
a  finger's  breadth  to  the  outside  of  the  line  of  incision.     Draw  the 


Fig.   285. — Exposure  of  the  ulnar  nerve  in  the   upper  third  of  the  arm.      M.  N.  Median 
nerve.     B.  A.  Brachial  artery.  U.  N.  Ulnar  nerve.      Tr.  Triceps  muscle.      {Schwartz.) 

basilic  vein  to  one  side.  Carefully  divide  the  subjacent  tissue  be- 
neath which  is  the  ulnar  and  median  nerves  and  the  brachial  artery; 
the  ulnar  nerve  is  to  the  inside  and  in  contact  with  the  long  head  of 
the  triceps.     (Fig.  285). 

(B)  At  the  elbow  (Fig.  286):  Place  the  patient  on  the  back;  abduct 
the  arm;  flex  the  forearm  at  a  right  angle;  stand  to  the  inner  side 
of  the  arm  and  locate  the  inner  condyle,  the  olecranon  and  the  in- 
tervening gutter.     Along  the  line  of  the  gutter  incise  the  skin  and  the 


364 


INJURY   AXD   REP.\IR    OF    NERVES 


Fig.   286. — Exposure  of  the  ulnar  nerve  at  elbow.     I.   C.   Internal  condyle.     E.  C.  U 
Extensor   carpi   ulnaris.     U.    X.    Ulnar   nerve.      Olec.    Olecranon   process.      Trie.    Triceps. 
{Schwartz.) 


Fig.  287. — Exposure  of  the  ulnar  nerve  at  the  wrist.     U.  A.  Ulnar  artery.     U.  N.  Ulnar 

nerve.  (Schwartz.) 
(C)  In  the  lower  third  of  the  forearm:  Following  the  line  of  the  nerve,  from  the  internal 
condyle  to  the  radial  side  of  the  pisiform,  make  an  incision  2  inches  long  to  the  outside 
of  the  flexor  carpi  ulnaris,  dividing  the  skin  and  superficial  fascia.  Retract  inward  the 
tendon  of  this  flexor.  Carefully  incise  the  deep  fascia  and  the  nerve  is  exposed  lying  to  the 
ulnar  side  of  the  ulnar  artery. 


[[[repair  of  the  musculo-spiral  365 

fascias  for  2  or  3  inches,  and  the  nerve  will  be  exposed,  accom- 
panied by  the  posterior  ulnar  recurrent  artery. 

(D)  In  the  wrist  (see  Fig.  287). 

Musculo-spiral. — The  musculo-spiral,  more  than  any  other  nerve 
of  the  arm,  is  subject  to  injury  from  stab,  contused,  or  gunshot 
wounds  or  to  fracture  of  the  humerus.  Very  characteristic,  too,  are 
the  symptoms  resulting  from  its  loss  of  function.  The  wrist  and 
fingers  cannot  be  extended  and  assume  the  attitude  well  known  as  the 


Sup.  Long. 
■:ii'  •■    Mus.  Sp. 
'""    Br.  Ant. 


Fig.  288. — Exposure  of  the  musculo-spiral  in  its  lower  third.     The  supinator  longus  is  exposed 
and  the  nerve  found  to  its  inner  side  lying  upon  the  brachialis  anticus.      {Schwartz.^ 

"drop  wrist."  In  every  fracture  of  the  humerus,  the  stabiUty  of  this 
nerve  should  be  tested.  The  nerve  may  be  explored  in  any  part  of 
its  course,  but  is  most  easily  reached  at  the  outer  side  of  the  arm  just 
above  the  elbow. 

To  Expose  the  Musculo-spiral. — In  the  lower  third  of  the  arm  (Fig. 
288):  The  arm  is  abducted,  the  forearm  extended  and  the  hand 
supinated.  Stand  to  the  outside  of  the  limb.  In  the  line  of  the 
nerve,  a  line  drawn  along  the  middle  of  the  external  surface,  begin- 
ning half-way  between  the  shoulder  and  elbow  and  extending  to  a 
point  y^  inch  from  the  center  of  the  bend  of  the  elbow,  make  an 


366 


INJURY   AND   REPAIR    OF    NERVES 


incision  2  or  3  inches  in  length  through  the  skin  and  superficial 
fascia.  Retract  the  cephaUc  vein.  Divide  the  deep  fascia  along  the 
border  of  the  supinator  longus  and  expose  the  muscle  fully.  Retract 
it  to  the  outside.  At  the  bottom  of  the  wound  is  the  nerve  lying  upon 
the  brachialis  anticus  fsee  page  139,  Gunshot  Wounds). 


Fig.  283. — Exposure  of  the  circumflex  nerve.  D.  Deltoid.  T.  M. 
Triceps.  T.  Maj.  Teres  major.  C.  A.  Circumflex  artery.  C.  X. 
(^Schwartz.) 


Teres  minor.     Tr. 
Circumflex    nerve. 


Circumflex. — In  addition  to  such  injuries  as  may  be  due  to  stab  or 
gunshot  wounds,  the  circumflex  is  liable  to  be  lacerated  in  violent 
wrenching  or  in  dislocation  of  the  shoulder-joint. 

The  immediate  result  is  loss  of  power  to  abduct  the  arm  through 
paralysis  of  the  deltoid.  The  nerve  may  be  exposed  as  it  winds 
around  the  humerus  just  below  its  head. 

Operation. — The  course  of  the  nerve  is  in  a  line  drawn  from  the 
inner  end  of  the  scapular  spine  to  the  point  of  insertion  of  the  deltoid. 


REPAIR   OF   THE   MUSCULO-CUTANEOUS 


367 


Place  the  patient  on  the  sound  side,  exposing  the  shoulder  well  by 
rotating  the  arm  inward  a  little  and  placing  it  in  front  of  the  trunk. 

Along  the  line  indicated  make  an  incision  3  or  4  inches  long, 
corresponding  at  its  outer  end  to  the  acromion  process,  but  an  inch 
or  two  from  it.  This  incision  divides  the  skin  and  superficial  and  deep 
fascia  and  exposes  the  posterior  border  of  the  deltoid.  Bring  into 
view  and  draw  upward  this  border  of  the  deltoid. 

Next  locate  the  quadrilateral  space,  bounded  above  by  the  teres 
minor,  below  by  teres  major,  posteriorly  by  the  long  head  of  the  tri- 


FlG.  290. — Exposure  of  the  musculo-cutaneous  nerve  in  the  middle  third  of  arm.  The 
biceps  (B)  drawn  outward  exposes  the  nerve  (M.  Cut.  X.)  lying  to  the  outside  of  the  median 
nerve  (Med.  N.)  and  the  brachial  artery,  Br.  Art.      {Schwartz.) 


ceps,  and  anteriorly  by  the  shaft  of  the  humerus.  By  locating  the 
tendons  of  these  muscles  define  this  space  in  which  lie  the  nerve 
and  the  posterior  circumflex  artery  (Fig.  289). 

The  musculo-cutaneous  is  exposed  in  the  same  manner  as  the  me- 
dian in  the  upper  third  of  the  arm  (Fig.  290). 

Anterior  Crural. — The  division  of  the  anterior  crural  nerve  means, 
among  other  things,  loss  of  extension  of  the  leg. 

To  outline  it  locate  the  spine  of  the  pubes  and  the  anterior-superior 
iliac  spine,  which  points  are  connected  by  Poupart's  hgament;  under 


368 


INJURY   AND   REPAIR    OF    NERVES 


this  ligament  a  finger's  breadth  outside  of  its  middle  point  the  nerve 
passes  (Fig.  291). 

To  Expose  the  Anterior  Crural. — Make  an  incision  from  this  point 
downward  in  the  axis  of  the  thigh,  about  3  inches  in  length,  divid- 
ing the  skin. 

At  the  upper  end  of  the  wound  expose  the  lower  border  of  Poupart's 
ligament.     Immediately  below  this  line,  open  up  the  sheath  of  the 


Fig.   291. — Anterior  crural  and  external  cutaneous  nerves.      {Labey.) 


psoas  magnus,  pass  a  grooved  director  under  the  sheath,  and  divide 
it  to  the  same  extent  as  the  skin  incision.  Separating  the  Hps  of 
the  sheath  wound,  the  nerve  is  seen  lying  on  the  fibers  of  the  muscle 
and  is  to  be  distinguished  by  its  whiteness  and  its  subdivisions. 

The  Obturator. — If  the  obturator  is  divided,  there  follows  loss  of 
abduction  of  the  thigh. 

To  Expose  the  Obturator.— Ahduci  the  thigh  until  the  border  of  the 
adductor  longus  can  be  clearly  defined,  and  along  this  line  make  an 
incision  4  or  5  inches  long,  beginning  an  inch  below  the  fold  of  the 


INJURY   TO    THE    SCIATIC   NERVES 


369 


groin,  a  little  to  the  outside  of  the  scrotal  base.  Divide  the  skin  and 
superficial  fascia,  retracting  to  the  outer  side  the  internal  saphenous 
vein,  but  ligating  its  cross  branches  (Fig.  292).  Divide  the  deep 
fascia  in  the  same  line. 

Separate  the  adductor  longus  from  the  pectineus  by  blunt  dissec- 
tion. A  fairly  well-defined  gutter  indicates  the  line  of  separation. 
Retract  the  two  muscles  and  at  the  bottom  of  the  upper  part  of  the 
wound  you  will  see  the  obturator  nerve,  consisting  of  a  couple  of 
flattened  cords.     Now  extend  the  thigh  to  relax  the  abductors  and 


Fig.   292. — Exposure  of  the  obturator  nerve;  separating  the  adductor  longus  from 

the  pectineus.      {Labey.) 


separate  more  widely  the  two  muscles  mentioned  and  the  nerve  may 
be  completely  exposed,  one  branch  lying  upon  the  adductor  brevis 
and  the  other  passing  under  it  (Fig.  293). 

Ilio-inguinal  and  Genito-criiraL — These  nerves  are  frequently 
wounded  in  hernia  operations,  and  may  give  rise  to  an  obstinate 
neuralgia  of  the  testicle  requiring  removal  of  this  organ.  In  such  a 
case  an  effort  should  first  be  made  to  repair  the  nerve  or  resect  it. 

The  Sciatic  Nerve.~T\iQ  sciatic  nerve  may  be  injured  in  many 
24 


370 


INJURY   AND    REPAIR    OF   NERVES 


ways  and  from  the  functional  point  of  view,  these  injuries  are  always 
serious.  It  may  mean  loss  of  extension  of  the  thigh  and  complete 
paralysis  of  the  leg. 

It  may  be  exposed  at  any  part  of  its  course  down  the  back  of  the 
thigh. 

Exposure  in  the  Middle  of  the  Thigh. — Place  the  patient  face  down- 
ward or  on  the  sound  side.  Along  the  line  of  the  nerve  (a  straight 
line  extending  from  a  point  midway  between  the  ischial  tuberosity 
and  the  great  trochanter  to  the  middle  of  the  popHteal  space),  make 


Fig.  293. — Obtiirator  exposed.     {Labey.) 


an  incision  3  or  4  inches  long,  dividing  the  tissues  down  to  the 
deep  fascia.  Determine  the  interspace  between  the  biceps  and  the 
internal  hamstring,  and  over  it  divide  the  deep  fascia  and  separate  by 
blunt  dissection  the  muscles  of  the  space. 

Flex  the  leg  so  as  to  relax  them.  They  are  then  to  be  retracted 
widely  and  in  the  fatty  tissues  of  the  interval  the  nerve  is  usually  eas- 
ily found. 

The  External  Popliteal,  or  Peroneal. — -This  nerve,  like  others,  is 
liable  to  injury  in  fractures  and  wounds.     When  it  is  divided,  ''foot 


REPAIR    OF   THE   PERONEAL 


371 


drop"  occurs.  The  patient  cannot  walk  without  stubbing  the  great 
toe  and  to  prevent  this,  the  whole  leg  is  raised  (steppage  gait). 
This  nerve  bears  an  important  relation  to  the  knee-joint  and  to  the 
tendon  of  the  biceps. 

To  expose  the  peroneal  behind  the  head  of  the  fibula  place  the 
patient  face  downward  or  on  the  sound  side.  The  line  of  the  nerve 
corresponds  to  the  tendon  of  the  biceps,  which  may  be  palpated 
along  the  external  border  of  the  popliteal  space,  or  the  course  of  the 
nerve  may  be  indicated  by  a  line  drawn  from  the  tuberosity  of 
the  ischium  to  the  head  of  the  fibula.  In  this  line,  beginning  at  the 
neck  of  the  fibula,  make  an  inci- 
sion upward  3  inches  long,  divid- 
ing the  structures  down  to  the 
deep  fascia.  Carefully  divide  the 
deep  fascia  over  the  tendon  of 
the  biceps  and  at  once  there  comes 
into  view  the  external  popliteal, 
lying  to  the  inner  side  of  the 
tendon  resting  upon  the  external 
condyle  of  the  femur  above,  and 
lower  down  winding  about  the 
neck  of  the  fibula  and  disappear- 
ing in  the  peroneus  longus. 

To    Expose    the    Musculo-cuta- 
neoiis. — -Place    the   patient   upon 

his  back,  the  knee  flexed  and  rotated  inward,  and  retained  by  a 
cushion  placed  under  the  thigh;  in  this  manner  exposing  the  ex- 
ternal aspect  of  the  leg. 

The  line  of  the  nerve  is  drawn  from  the  anterior  border  of  the  pero- 
neal head  to  the  anterior  border  of  the  external  malleolus.  Along 
this  fine,  in  the  middle  of  the  leg,  make  an  incision  3  or  4  inches 
in  length  dividing  the  structures  to  the  deep  fascia. 

Incise  the  aponeurosis  of  the  peronei  muscles,  isolate  the  anterior 
border  of  the  peroneus  longus  and  draw  it  backward.  The  muscle 
may  be  previously  relaxed  by  rotating  the  foot  outward.  The  nerve 
will  be  seen  resting  upon  the  peroneus  brevis  (Fig.  294). 

The   Anterior    Tibial   Nerve. ^T\\t   anterior    tibial  nerve   is   the 


Fig    294. — Musculocutaneous  nerve  lying 
upon  the  peroneus  brev-is.     {Lahey.) 


372 


INJURY   AND   REPAIR   OF   NERVES 


continuation  of  the  external  popliteal  nerve.  The  movements 
of  flexion  of  the  foot  and  extension  of  the  toes  depend  upon  this 
nerve. 

To  Expose  the  Anterior  Tibial  Nerve. — -(A)  In  the  upper  third: 
Put  the  patient  in  the  same  position  as  for  the  musculo-cutaneous. 

The  line  of  the  nerve  is  drawn  from  the  front  of  the  peroneal  head 
to  the  middle  of  the  anklejoint  (Fig.  295). 

In  the  line  of  the  nerve  make  an  incision  beginning  three  fingers' 
breadth  below  the  articular  line  of  the  knee.  Divide  to  the  deep 
fascia;  next  divide  that  and  then  patiently  search  for  the  intermus- 
cular septum  separating  the  wide  tibialis  anticus  from  the  narrow 
common  extensor.  It  will  aid  greatly  in  the  search  to  seize  with  a 
forceps  each  of  the  lips  of  the  wound  of  the  sheath  and  retract. 
This  will  help  to  develop  the  line  of  cleavage. 


Fig.  2QS- — Lines  representing  the  course  (c)  of  the  musculo-cutaneous; 
{ah)    Anterior  tibial  nerves.      LLabey.) 


Remember  that  the  tibialis  anticus  slightly  overlaps  the  common 
extensor,  so  that  the  intermuscular  space  slopes  inward  and  back- 
ward. Retracting  the  muscles,  the  nerve  will  appear  as  a  small 
rounded  white  cord  lying  in  front  of  the  vessels. 

(B)  In  the  lower  third  (see  Anterior  Tibial  Artery). 

Posterior  Tibial  Nerve. — The  posterior  tibial  nerve  supplies  the 
movements  of  the  extension  of  the  foot  and  flexion  of  the  toes  and 
may  be  wounded  in  any  part  of  its  course,  although  in  the  region 
of  the  calf  it  is  deeply  situated.  Behind  the  internal  malleolus 
it  is  superficial  and  easily  exposed. 

(A)  To  Expose  Upper  Third. — -To  expose  the  posterior  tibial  in 
the  region  of  the  calf  is  difiicult  (Fig.  296). 

Position. — ^Place  the  patient  on  his  back  with  the  thigh  in  abduction 


REPAIR    OF    THE    POSTERIOR    TIBIAL 


373 


and  external  rotation,  the  knee  flexed,  and  the  foot  lying  upon  its 
external  border  and  held  in  this  position  by  an  assistant.  Standing 
to  the  outside  of  the  limb  the  operator  with  this  arrangement  can 
see  quite  well  the  internal  surface  of  the  leg. 


Fig.   296. — Exposure  of  the  post,   tibial  nerve.     Gastrocnemius  retracted; 
soleus  exposed,     (Labey.) 


.f 


Fig.  297. — Fibers  of  the  soleus  divided  and  retracted,  exposing  deeply 
situated,  the  posterior  tibial  nerve  and  artery.     (Labey.) 

Locate  first  the  sharp  internal  border  of  the  tibia,  and  a  finger's 
breadth  behind  it  make  an  incision  4  inches  long,  beginning  at  the 


374  INJURY    AND    REPAIR    OF    NERVES 

level  of  the  tuberosity.  Divide  the  tissues  down  to  the  deep  fascia, 
avoiding  the  internal  saphenous  vein,  which  Hes  close  to  the  tibial 
border. 

Slightlv  retract  the  posterior  lip,  which  will  include  the  gastrocne- 
mius, and  in  this  manner  the  soleus  is  exposed.  Division  of  the 
soleus  is  the  next  step  which  must  be  carefully  carried  out.  Divide  it 
longitudinallv,  but  further  away  from  the  tibia  than  the  original  in- 
cision. Cutting  in  this  manner  through  the  fibers  of  the  soleus,  the 
yellow  aponeurosis  covering  the  nerve  and  vessels  is  exposed  (Fig.  297). 
It  is  important  to  expose  this  landmark  wtII.  Make  an  opening  in  it 
an  inch  and  a  half  from  the  internal  border  of  the  tibia,  and  beneath 
the  opening  is  the  nerve,  lying  to  the  outer  side  of  the  artery. 

(B)  Behind  the  ankle  (see  Ligation  of  Posterior  Tibial  Artery). 


CHAPTER  XXI 
ABSCESS 

An  abscess  is  a  circumscribed  collection  of  the  liquefied  products 
of  infective  inflammation. 

There  are  two  kinds  of  abscesses,  differing  in  their  etiology,  clinical 
history,  prognosis,  and  treatment.  All  these  differences  arise  pri- 
marily in  the  nature  of  the  infective  agent.  The  acute  abscess  is  due 
most  generally  to  the  activity  of  certain  of  the  cocci.  The  chronic 
(or  cold)  abscess  is  nearly  always  due  to  the  Bacillus  tuberculosis. 
The  chronic  abscess  may  become  infected  secondarily  with  the  germs 
of  acute  inflammation,  in  which  instance  it  takes  on  the  character 
of  the  acute  abscess. 

The  content  of  the  acute  abscess  is  pus;  that  of  the  chronic  abscess, 
though  resembling  pus,  may  be  merely  the  liquefied  caseated  matter 
of  the  tubercle  without  any  pus  cells  whatever.  An  acute  abscess 
presents  all  the  cardinal  symptoms  of  inflammation:  constitutional 
disturbance,  pain,  heat,  redness,  swelling,  all  in  greater  or  less 
degree,  depending  on  the  locality.  A  chronic  abscess  may  present 
none  of  these  symptoms  except  swelling,  and  where  swelling  is  not 
perceptible  the  abscess  is  frequently  unsuspected.  An  acute  ab- 
scess is  of  very  rapid  development — the  chronic  of  quite  slow  growth, 
as  a  rule.  An  acute  abscess  demands  immediate  evacuation  by 
free  incision  and  drainage.  The  chronic  abscess  very  often  per- 
mits only  of  aseptic  puncture,  followed  by  the  injection  of  deter- 
gent remedies,  and  aseptic  occlusion. 

Each  occurs  by  choice  in  certain  locations.  The  incision,  the 
special  dangers  and  details  of  treatment  depend  on  the  anatomy  of 
the  parts,  so  that  the  more  common  abscesses  require  individual 
consideration,  and  in  that  connection  the  general  principles  that 
underlie  the  subject  may  be  elaborated. 

The  prevention  of  pus  formation  should  be  attempted  in  all  acute 

375 


376  ABSCESS 

infectious  inflammations  by  means  of  the  timely  application,  in 
favorable  localities,  of  hot  antiseptic  poultices  or  prolonged  immer- 
sion in  hot  antiseptic  solutions.  Even  though  the  treatment  fails 
to  prevent  suppuration,  it  will  at  least  limit  it.  Such  an  antiseptic 
poultice  may  be  made  by  applying  absorbent  cotton  soaked  in  hot 
boric  acid  solution  and  covering  it  with  oiled  silk  or  gutta-percha. 
In  this  manner  heat  and  moisture  are  retained. 

The  old  flaxseed-meal  poultice  is  more  often  than  not  the  breeder 
of  germs  and  therefore  distinctly  non-surgical — a  domestic  make- 
shift. Some  of  the  "antiphlogistic"  glycerinated  and  sterile  clay 
pastes  often  render  an  excellent  service. 

Treatment. — The  evacuation  of  an  abscess  is  by  many  regarded 
as  a  small  procedure  in  minor  surgery.  It  may  be  nothing  more, 
and  yet,  as  Lejars  says,  in  certain  cases  it  is  a  formidable  task 
straining  the  resources  of  the  most  practised.  It  is  an  idea  too  long 
prevalent  that  there  is  a  minor  and  a  major  surgery.  There  is  only 
one  kind  of  good  surgery,  whether  the  case  is  of  great  or  httle  im- 
portance. It  is  that  which  recognizes  the  indications  and  meets 
them  promptly,  giving  the  patient  relief  with  the  least  possible 
delay. 

Abscesses  have  too  much  been  regarded  as  simple  conditions  which 
the  merest  tyro  might  treat.  We  all  know  of  patients  w^ho  have 
died  of  these  operations;  of  others  who  have  been  disabled  by  the 
failure  to  perform  them,  or  by  their  being  tardily  or  improperly 
done.     And  how  often  tardily  done! 

But  what  excuse  can  one  make  for  delay  after  pus  has  definitely 
formed,  for  any  attempt  to  bring  about  its  absorption  is  futile. 
Delay  merely  means  that  the  collection  augments,  destroys  more 
tissues,  acquires  diverticula  without  end,  which  may  need  to  be 
opened  up  time  and  time  again,  or  may  require  months  to  heal, 
and  eventually  give  rise  to  irremediable  contractions  and  adhesions. 

It  is  one  of  the  most  important  and  least  varying  rules  of  surgical 
practice  that  every  acute  abscess,  superficial  or  deep,  must  as  early 
as  possible  be  incised,  emptied,  and  drained. 

Another  point:  do  not  wait  ior  fluctuation,  which  is  so  commonly 
the  practice.  If  the  suppuration  occurs  in  the  deeper  structures, 
fluctuation   may   be   delayed.     But    there   are    ample   indications 


ACUTE    ABSCESS  377 

otherwise;  the  rapid  increase  of  swelling,  the  radiating  pains, 
fever,  and  subcutaneous  edema  give  sufficient  evidence  that  pus  is 
present. 

In  certain  regions,  the  thick  and  brawny  skin  and  fascia  is  as 
significant  as  fluctuation  itself.  On  the  scalp,  for  instance,  this 
brawny  edema  is  a  definite  symptom  of  suppuration. 

The  edema  is  superficial;  the  suppuration,  deep.  The  two 
processes  go  together  and  when  the  first  is  present,  one  may  un- 
hesitatingly diagnosticate  the  second. 

To  repeat,  when  the  skin  pits  on  pressure  and  is  only  slightly  red- 
dened even,  the  diagnosis  is  no  longer  doubtful  and  one  may — one 
should — operate  at  once. 

The  length  of  the  incision  is  of  the  greatest  importance.  Nothing 
is  more  unsatisfactory  than  the  mere  stab,  or  puncture,  of  an  acute 
abscess.  The  incision,  cutting  through  the  middle,  parallel  with 
the  most  important  structures,  should  open  up  the  whole  length  of 
the  cavity.  In  this  manner  no  pockets  are  left  behind,  and,  be- 
sides, a  long,  smooth  incision  will  in  the  end  leave  the  least  scar.  A 
counter-incision  may  be  necessary. 

Once  the  abscess  is  opened  and  the  pus  has  ceased  to  flow,  wipe 
out  the  cavity  with  sterile  gauze  and  irrigate  with  sterile  water  or 
some  antiseptic.  If  diverticula  are  found,  they  too  must  be  freely 
opened  up  and  irrigated. 

Insert  a  drain.  If  the  abscess  was  small  and  the  incision  made 
early,  it  is  proper  to  dispense  with  the  drain;  but  if  the  suppuration 
is  extensive,  the  best  means  of  preventing  large  scar  formation  is  to 
employ  drainage. 

Observe,  then,  says  Lejars,  that  the  whole  therapy  of  abscesses  is 
contained  in  these  two  words,  "empty"  and  "drain." 

You  do  nothing  more — there  is  nothing  more  to  be  done — and 
it  is  sufficient.  To  attempt  to  make  an  abscess  cavity  aseptic  is 
wasted  eflfort.  An  abscess  contains  infection  of  limited  virulence 
and  when  once  it  is  emptied,  the  Uving  tissues  will  do  the  rest,  pro- 
vided they  are  not  embarrassed  by  new  germs  introduced  by  the 
operation. 

With  this  notion  in  view,  then,  it  must  be  an  absolute  rule  of 
practice  to  operate  for  abscess  with  clean  hands  and  clean  instru- 


378  ABSCESS 

ments  in  a  carefully  disinfected  field.  We  may  put  away  for  all 
time  the  old  dictum,  ''If  pus  is  present,  antisepsis  is  useless." 

Disinfect  the  hands,  or  what  is  better,  the  gloves;  boil  the  instru- 
ments; cleanse  the  affected  area  with  soap  and  alcohol  and  bichloride 
or  simply  paint  with  Tr.  iodine;  then,  and  then  only,  are  you  ready 
to  incise  the  swelling.  Wipe  out  with  sterile  gauze;  use  sterile  tubes. 
Do  not  pack  with  gauze;  there  is  nothing  more  illogical  than  tam- 
ponade of  an  abscess  cavity.  Cover  the  wound  with  sterile  gauze 
and  absorbent  cotton,  and  bandage  firmly  so  that  nothing  may  enter 
the  wound;  so  that  the  dressings  will  not  slip  or  rub. 

The  dressings  are  to  be  changed  daily  at  first  and  the  tubes  every 
second  or  third  day,  and  are  to  be  shortened  as  the  cavity  fills  up 
with  granulations;  are  to  be  dispensed  with  when  pus  has  ceased 
to  form. 

Treatment  of  Cold  Abscess. — The  treatment  of  a  cold  abscess 
differs  from  that  of  an  acute  abscess  in  that  incision  is  not  the  method 
of  choice. 

There  is  always  great  danger  of  infection  when  the  abscess  cavity 
is  opened  up  and  for  that  reason  incision  must  be  done  with  circum- 
spection— with  an  absolute  asepsis.  There  is  not  the  urgency  present 
in  the  acute  case. 

Puncture  is  the  method  of  choice.  Employ  the  strictest  anti- 
sepsis. Wash  with  soap  and  water,  but  not  too  vigorously  lest  the 
abscess  wall  be  ruptured;  complete  the  disinfection  with  alcohol 
and  ether.  Employ  only  such  instruments  as  are  carefully  steriHzed. 
Use  a  trocar  of  sufficient  size  that  the  grumous  fluid  will  not  occlude 
it.  Do  not  puncture  the  summit  of  the  tumor  if  the  skin  is  quite 
thin,  but  select  a  point  where  the  tissues  are  sufficiently  resistant 
to  close  when  the  trocar  is  withdrawn.  At  the  end  of  the  evacuation 
the  fluid  may  need  to  be  aspirated.  It  may  be  discolored  by  some 
blood  from  the  puncture. 

Injection  with  some  stimulating  and  antiseptic  fluid  should  follow. 
Ethereal  solution  of  iodoform  has  the  advantage  of  distending  the 
cavity  by  gas  formation  and  reaching  all  the  diverticula;. but  it  has 
the  disadvantage  that  it  is  toxic.  Inject  5  to  10  c.c.  of  a  10  per 
cent,  solution;  leave  the  trocar  in  place,  closing  its  orifice  with  the 
finger.     When  the  cavity  becomes  distended,  remove  the  finger  and 


CHRONIC   ABSCI':SS  379 

the   ether  spurts  out.     Let  all  the  gas  escape.     If  one  does  not 
observe  this  rule  there  may  be  a  slough. 

A  solution  of  iodoform  in  glycerine  may  be  employed;  inject  3  to  10 
grams  of  a  10  per  cent,  solution,  letting  the  surplus  escape.  Cam- 
phorated naphthol  may  be  used  in  the  same  way.  Bismuth  paste  in 
certain  localities  serves  an  excellent  purpose.  After  the  injection 
is  completed  seal  the  puncture  with  collodion.  Several  injections 
may  be  necessary  for  a  cure.  Constitutional  treatment  is  of  the 
greatest  importance. 

ABSCESSES  OF  THE  SCALP 

These  are  found  in  three  locations: 

1.  Superficial — that  is,  above  the  aponeurosis  of  the  occipito- 
frontalis. 

2.  Subaponeurotic — that  is,  between  aponeurosis  and  the  perios- 
teum. 

3.  Subperiosteal — between  the  periosteum  and  the  bone. 

1.  Superficial  abscess,  due  to  staphylococci,  is  quite  localized, 
and  yet  very  painful  on  account  of  the  resistance  of  the  firm  tissue. 
The  lymph  nodes  behind  the  ear  and  in  the  back  of  the  neck  are 
enlarged  and  tender.  The  chief  danger  is  in  extension  to  the  deeper 
layers;  or  the  emissary  veins  may  carry  infection  to  the  sinuses  and 
produce  thrombosis  or  pyemia.  Evacuate  immediately  by  free 
incision,  first  shaving  the  scalp  in  the  immediate  vicinity  of  the 
abscess. 

Remembering  the  manner  in  which  the  occipital  and  temporal 
arteries  converge  toward  the  apex,  the  incision  may  be  managed  in 
such  a  way  as  to  run  parallel  to  the  small  vessels  distributed  to  the 
area. 

The  cavity  must  be  kept  open  by  a  strip  of  rubber  tissue  or  a  small 
drainage-tube.  A  dressing  of  gauze,  absorbent  cotton  and  bandage 
complete  the  treatment.     Change  the  dressing  every  day  at  first. 

2.  Subaponeurotic  abscess  is  Hkely  to  follow  wound  infection. 
The  streptococci  follow  the  areolar  tissues  that  separate  the  aponeu- 
rosis from  the  periosteum,  and  the  spread  of  pus  is  limited  only  by 
the  attachments  of  the  aponeurosis-     Septicemia,  meningitis,  and 


380  ABSCESS 

thrombosis  are  the  actual  dangers,  and  on  these  accounts  immediate 
operation  is  demanded. 

Make  a  free  incision  under  antiseptic  precautions;  that  is,  after 
shaving  and  cleansing  the  part  involved. 

Do  not  attempt  irrigations,  above  all,  in  these  cases,  for  the  fluid 
percolating  through  the  loose  areolar  tissues  spreads  the  infection. 
Good  drainage  alone  will  suffice.  The  dressings  must  be  changed 
frequently  at  first  and  must  be  firm  enough  to  prevent  movement  of 
the  occipito-frontalis  muscle. 

If  the  abscess  develops  under  the  temporal  fascia,  it  will  not  point 
toward  the  surface,  owing  to  the  extreme  density  of  this  fascia,  but 
toward  the  mouth  or  neck  through  the  ptergo-maxillary  fossa. 
Even  though  there  be  no  fluctuation  (usually  indeed,  none  can  be 
detected),  the  diagnosis  can,  nevertheless,  be  certainly  made  from 
the  presence  of  the  edema,  redness,  and  pain.  Make  a  vertical  in- 
cision an  inch  or  so  in  front  of  the  ear  and  with  the  center  about  the 
level  of  the  eyebrow.  It  may  be  necessary  to  go  through  the  sub- 
stance of  the  muscle  to  the  bone.  A  few  small  arteries  will  be  divided 
and  will  require  ligation.  It  may  be  necessary  at  the  first  dressing  to 
pack  the  cavity  with  gauze  to  control  slight  but  persistent  bleeding. 
Drainage  by  means  of  tubes  may  be  employed  subsequently. 

3.  Subperiosteal  abscesses  differ  from  the  others  in  that  they 
are  likely  to  be  the  result  of  bone  inflammation,  tubercular  or 
syphilitic.  The  abscesses  are  limited  to  the  area  of  one  bone  as  the 
periosteum  along  the  line  of  the  sutures  is  continuous  with  the 
dura  mater.  This  furnishes  an  easy  means  of  entrance  into  the 
cranial  cavity  for  the  infection  and  in  that  manner  meningitis  may 
result.  For  this  reason,  these  abscesses,  of  whatever  origin,  should 
be  evacuated  at  once  and  appropriate  constitutional  treatment 
instituted. 

ABSCESS  AND  FURUNCLE  OF  THE  FACE 

The  danger  in  these  conditions  is  that  phlebitis  beginning  in  the 
facial  vein  may  spread  to  the  cavernous  sinus,  so  free  is  the  com- 
munication by  numerous  branches  between  these  venous  channels. 
Especially  to  be  feared  are  these  furuncles  beginning  on  the  upper 


ABSCESS   OF   THE   FACE  381 

lip  or  median  parts  of  the  face.  They  may  be  fatal  in  a  few  days. 
Nearly  always  the  staphylococcus  pyogenes  is  the  active  causative 
agent  and  one  need  not  usually  be  at  a  loss  to  trace  the  mode  of 
entrance  of  the  infection. 

Early  incision  is  imperative  in  all  such  acute  septic  processes. 
The  best  form  of  local  anesthesia  in  these  conditions  is  by  freezing 
with  ethyl  chloride  spray.  Hypodermic  injections  are  best  avoided 
here.  The  incision  must  be  deep  to  be  effective,  and  in  making  it 
two  factors  are  to  be  borne  in  mind,  the  resulting  scar  and  injury 
to  the  branches  of  the  facial  nerve.  In  severe  cases  even  these  points 
must  be  disregarded.  Even  more  certain  than  free  incision  is  central 
puncture  with  a  fine  thermo-cautery,  followed  by  the  Bier  suction 
treatment.  If  it  is  a  carbuncle  of  the  diffuse  type,  accompanied  by 
edema  of  the  face  and  inflammation  of  the  veins,  crucial  incision  with 
curettement  must  be  undertaken.  The  dressing  of  gauze  may  be 
held  in  place  by  adhesive  strips. 

ABSCESS  OF  THE  NASAL  SEPTUM 

Following  a  blow  upon  the  nose,  bleeding  ensues  and,  two  or  three 
days  later,  obstruction.  Looking  into  the  child's  nasal  fossae,  they 
are  seen  to  be  filled  with  a  bright  red,  tender,  fluctuating  swelling, 
over  the  cartilaginous  portion  of  the  septum.  The  whole  nose 
becomes  hot,  swollen,  and  painful. 

The  treatment  is  evacuation  by  a  free  incision  of  the  mucous 
membrane  over  the  septum  at  the  point  of  greatest  fluctuation. 

To  operate,  apply  a  4  per  cent,  solution  of  cocaine  to  the  mucous 
membrane,  and  after  waiting  a  minute  or  two,  make  an  incision 
along  the  septal  wall  from  above  downward  and  forward  with  a 
slender,  sharp  bistoury.  Douche  the  nasal  fossa  frequently  with  a 
mild,  alkaline  antiseptic.  Recovery  usually  follows  within  a  week, 
although  in  the  neglected  cases,  necrosis  of  the  cartilage  may  occur. 

ABSCESS  OF  THE  EYELIDS 

The  loose  connective  tissues  of  the  eyelids  favor  exudation  and 
edema.     An  abscess  occurring  here  is  usually  due  either  to  trauma- 


382  ABSCESS 

tism  or  to  septic  infection  entering  from  the  face  or  scalp  or  to 
periostitis  of  the  margin  of  the  orbit.  Early  treatment  of  con- 
tusions may  prevent  not  only  the  unsightly  discoloration  (''black 
eye'"),  but  also  a  later  abscess. 

To  prevent  discolorations  apply  cooling  or  evaporating  lotions  or 
wring  a  gauze  compress  out  of  ice-water  and  apply  to  the  lid,  re- 
newing the  compress  every  two  or  three  minutes.  Do  not  allow  the 
compress  to  cover  the  nose,  else  acute  coryza  may  result.  Apply 
in  this  manner  for  an  hour  and  repeat  every  second  or  third  hour  for 
twenty-four  hours.  A  solution  of  arnica  (2  oz.),  in  water  (i  pt.), 
may  be  applied,  or 

Ammonii  chloride,  i 

Alcohol,  I 

Aquae,  10 

If  discoloration  appears,  apply  flannel  cloths  wrung  out  of  hot  water, 
for  an  hour  at  a  time,  three  or  four  times  daily,  and  follow  with  gentle 
massage  for  five  to  ten  minutes.  Before  applying  the  heat  it  is 
better  to  smear  the  lid  with  vaseline.  Ointment  of  yellow  oxide  of 
mercury  is  excellent  to  use  with  massage.  If  an  abscess  appears 
make  an  incision  parallel  with  the  muscle  fibers.  Apply  antiseptic, 
absorbent  dressings. 


ABSCESS  OF  THE  LACHRYMAL  GLAND 

Abscess  of  the  lachrymal  gland  is  rare,  yet  doubtless  is  often  over- 
looked. It  is  seen  in  infancy,  usually  traceable  to  some  of  the  in- 
fectious diseases.  The  abscess  breaks  into  the  superior  cul-de-sac 
and  recovery  follows. 

ABSCESS  OF  THE  EXTERNAL  AUDITORY  MEATUS 

Abscess  of  the  external  meatus  is  extremely  painful  and  alarm- 
ing, but  in  fact  not  particularly  dangerous.  The  meatus  is  closed 
by  the  swelUng,  but  a  stab  ^viih  the  point  of  the  knife  or,  if  it  is  more 
deeply  situated,  an  incision  in  the  direction  of  the  long  axis  of  the 
meatus,  wdll  cause  a  speedy  disappearance  of  the  symptoms.     Gentle 


PAROTID   ABSCESS  383 

douching  with  an  antiseptic  solution,  and,  after  drying,  occlusion 
with  absorbent  cotton,  will  soon  complete  the  cure. 


ABSCESS  OF  THE  PAROTID  GLAND 

An  inflammation  begins  in  the  parotid  gland,  the  result  of  local 
infection  or  secondary  to  an  abdominal  disease  or  injury  (most  fre- 
quently involving  the  pancreas,  perhaps),  and  nearly  always  sup- 
puration follows.  The  severe  forms  are  dangerous;  happily,  how- 
ever, the  pus,  even  if  left  to  take  its  own  course,  works  its  way  to 
the  surface  or  points  at  the  phraynx.  It  may  burrow  down  to  the 
anterior  mediastinum.  The  special  dangers  are  meningitis,  septic 
poisoning,  and  thrombosis.  When  the  swelling  is  great,  pressure 
interferes  with  the  venous  current  and,  as  a  result,  cerebral  con- 
gestion, headache,  and  finally  delirium  ensue.  The  pus  may  open 
into  the  middle  ear  and  infection  by  that  route  reaches  the  brain. 
Suppuration  of  the  temporo-maxillary  articulation  may  follow. 

Treatment. — If,  when  the  swelling  first  appears,  a  probe  be  passed 
into  Stenson's  duct  and  the  gland  be  pressed  from  the  outside,  a  few 
drops  of  pus  may  be  squeezed  out  and  this  may  serve  to  head  off  a 
general  suppuration.  If  the  entire  gland  becomes  involved,  hot 
antiseptic  poultices  should  be  applied  to  hasten  the  localization  of 
the  pus.  As  soon  as  redness  and  edema  indicate  the  most  probable 
situation  of  the  pus,  an  effort  must  be  made  to  evacuate  it.  Several 
important  structures  are  to  be  avoided;  Stenson's  duct  (a  fistula 
is  Hkely  to  follow  its  division),  the  facial  nerve,  the  carotid  arteries, 
the  temporo-maxillary  vein  and  other  vessels  of  lesser  importance 
may  be  wounded. 

If  the  anterior  part  of  the  gland  is  involved,  the  incision  is  made 
parallel  with  and  below  Stenson's  duct.  The  skin  and  fascia  are 
divided  and  retracted  and  an  effort  is  made  to  burrow  into  the  depths 
of  the  gland  wdth  a  probe  or  grooved  director.  The  pus  follows  the 
connective-tissue  laminae  instead  of  the  lobules  of  the  gland,  and  it  is 
better,  if  possible,  to  avoid  dividing  the  glandular  substance.  If 
the  posterior  and  lower  part  of  the  gland  is  involved,  the  incision  should 
be  vertical,  with  its  center  a  Uttle  above  and  anterior  to  the  angle  of 
the  jaw.     The  temporo-maxillary  vein  will  be  seen,  running  parallel 


384 


ABSCESS 


to  the  incision  near  the  surface  of  the  gland, 
be  left  in  the  deeper  abscesses. 


A  drainage-tube  must 


DENTAL  ABSCESS 

These  painful  affections  are  not  to  be  neglected,  for  they  may 
lift  up  the  periosteum  and  result  in  necrosis  of  the  jaw.  Left  to  it- 
self, the  abscess  may  point  in  the  mouth,  less  frequently  on  the  face. 
It  begins  in  the  alveolar  process  from  infection  from  a  carious 
tooth.  It  makes  its  appearance  at  the  junction  of  the  cheek  and 
the  gum.     Inspection  and  palpation  make  the  diagnosis.     A  cotton 


M.H- 


^f/.j/:i 


Fig.  298. — Dental  abscess. 


Fig.  299. — Submaxillary  abscess 
in  contact  with  inner  surface  of  the 
inferior  maxilla.  M.  H.,  Mylohyoid 
muscle.  P.,  Platysma  myoides. 
GLs.M.,  Submaxillary        gland. 

(Veau.) 


tampon  soaked  in  2  per  cent,  cocaine  solution  is  laid  on  the  gum  for 
five  or  ten  minutes,  but  analgesia  will  not  be  complete.  Lift  the 
cheek  away  from  the  gum  as  far  as  possible,  and  with  a  sharp- 
pointed  bistoury,  wrapped  to  within  a  half-inch  of  the  point,  make 
a  horizontal  incision  and  cut  down  to  the  bone.  There  is  nothing 
to  fear  and  without  getting  deep  one  may  fail.  The  patient  may 
resist  further  efforts  or  the  field  may  be  obscured  by  blood  (Fig.  298). 
Order  an  antiseptic  mouth-wash  to  be  used  every  half-hour  at 
first,  and  the  pain  will  rapidly  disappear.  In  more  extensive  sub- 
periosteal abscess  of  the  jaws,  the  same  principle  of  procedure  should 
be  carried  out. 


INCISION   OF   SUBMAXILLARY   ABSCESS 


385 


SUBMAXILLARY  ABSCESS 

Do  not  await  fluctuation  in  acute  inflammations  in  this  locality. 
The  pain,  augmented  by  pressure,  the  brawny  edema  and  diffuse 
redness  are  sufficient  to  demonstrate  the  presence  of  pus.  The 
pus  is  not  always  easy  to  find,  for  it  is  deep,  often  subperiosteal 
and  in  contact  with  the  internal  surface  of  the  jaw,  and  is  generally 
due,  in  fact,  to  dental  infection  (Fig.  299). 


Fig.  300. — ^Incision  of  submaxillary  abscess.     Dotted  line  represents  the 
facial  artery.      {Veau.) 


Local  anesthesia  is  often  sufficient.  Locate  the  angle  of  the  jaw. 
This  is  often  difficult  on  account  of  the  edema.  A  finger's  breadth 
below,  and  following  the  body  of  the  jaw,  make  a  curved  incision 
(Fig.  300)  with  sUght  downward  convexity  about  3  inches  in 
length.  Remember  the  point  at  which  the  facial  artery  crosses  the 
body  of  the  jaw,  just  in  front  of  the  masseter.  Do  not  cut  deeper 
than  the  skin,  for  this  is  dangerous  ground.  Now  dissect  with 
forceps  and  grooved  director  the  subjacent  tissues,  making  haste 

25 


;86 


ABSCESS 


slowly  and  renewing  from  time  to  time  the  analgesia  or  injections 
as  the  patient  complains  of  pain. 

Carry  the  dissection  upward  and  inward  toward  the  inner  surface 
of  the  jaw,  and  with  patience  the  abscess  will  be  located.  As  it  is 
approached,  the  tissues  will  be  found  more  and  more  edematous 
and  filled  with  serum.  Having  once  cut  into  it,  enlarge  the  opening, 
always  too  small,  by  introducing  and  opening  an  artery  forceps. 
Irrigate  with  normal  salt  solution,  insert  one  or  two  small  drains, 
dress  with  antiseptic  gauze  and  absorbent  cotton,  and  renew  daily. 


Fig.  301. — Phlegmon  of  the  floor  of  the 
mouth.  The  tongue  is  pushed  to  the  oppo- 
site side  and  the  spread  downward  of  the 
purulent  collection  opposed  by  the  mylo- 
hyoid muscle.  GSL.,  sublingual  gland.  AL, 
lingual  artery.  CW,  salivary  duct.  GGL, 
genio-hyo-glossus.  GY,  genio-hyoid.  MY, 
hyo-glossus.     D,  diagastric.     (Veau.) 


Fig.  302. — Incision    for 
floor  of  mouth. 


phlegmon    of 
{Veau.) 


The  temperature  will  fall  rapidly.     After  five  or  six  days  the  drain- 
age may  be  diminshed  and  after  ten  days  entirely  removed. 


ABSCESS  OF  THE  FLOOR  OF  THE  MOUTH 

(Ludwig's  Angina) 

This  is  a  very  grave,  usually  fatal  condition,  originating  in  strepto- 
coccic infection  through  the  mucous  membrane  of  the  floor  of  the 
mouth.     It  more  frequently  occurs  in  adults,  though  childhood  is 


ludwig's  angina  387 

not  exempt.  Its  tendency  is  to  extend  into  the  neck,  following 
the  cellular  planes,  and  if  the  patient  does  not  die  early  from  septi- 
cemia, gangrene  may  occur.  In  a  very  few  hours  after  the  infection 
begins,  the  floor  of  the  mouth  becomes  brawny,  the  tongue  is  thrust 
up  against  the  hard  palate,  and  breathing  and  swallowing  markedly 
interfered  with.  If  anything  is  to  do  good,  it  must  be  done  at  once 
(Fig.  301). 

Try  the  antistreptococcic  serum — if  it  does  no  good,  it  will  at 
least  do  no  harm.  In  the  meantime,  operate.  Usually  a  general 
anesthesia  is  indispensable.  Make  an  incision  a  finger's  breadth 
below  the  body  of  the  jaw  about  3  inches  long  so  that  it  reaches 
beyond  the  median  line  (Fig.  302).     If  both  sides  are  equally  in- 

////     • 


Fig.  303. — Deep  incision   for  phlegmon  in  floor  of  mouth.     G.s.M.,   submaxillary   gland 
M.H.,  mylo-hyoid  muscle.     D,  digastric  muscle.     {Veau.) 

volved,  make  a  bilateral  incision.  One  may  perhaps  recognize  the 
platysma,  but  the  anterior  belly  of  the  digastric  must  be  demon- 
strated and  divided.  Next  expose  the  mylo-hyoid  and  divide  com- 
pletely (Fig.  303).  Having  now  reached  the  sublingual  space,  you 
may  find  merely  a  serous  exudate,  characteristic  of  this  form  of 
infective  inflammation.  Do  not  stop  until  the  mucous  membrane 
of  the  mouth  has  been  demonstrated,  for  otherwise  one  may  mis- 
take the  submaxillary  for  the  sublingual  gland  and  not  go  deep 
enough. 

Douche  thoroughly  with  peroxide,  place  two  or  three  large  drain- 
age-tubes, pack  with  gauze  saturated  with  peroxide,  and  apply 
absorbent  cotton.  Renew  the  dressings  and  flushing  three  or  four 
times  daily  and  the  serum  injections  as  well.  Possibly  the  patient 
will  go  on  rapidly  to  death  from  septicemia.     He  is  almost  certain 


388  ABSCESS 

to  do  so  without  the  operation.     The  drainac^e  may  be  diminished 
toward  the  tenth  day.     Several  weeks  will  be  required  for  a  cure. 

ABSCESSES  OF  THE  TONGUE 

Abscesses  of  the  tongue  do  not  often  occur,  but  when  they  do, 
mav  give  rise  to  urgent  conditions.  They  may  develop  suddenly 
with  much  pain,  which  may  be  variously  reflected — to  the  ear,  for 
example. 

The  tongue  may  be  so  swollen  as  to  fill  the  mouth  and  severely 
disturb  respiration.  The  location  of  the  abscess  is  to  be  determined 
by  palpation.  If  it  is  at  the  base  of  the  tongue  and  pointing  to- 
ward the  surface,  is  it  to  be  evacuated  by  a  median  longitudinal  in- 
cision from  behind  forward  and  deep  enough  to  reach  the  pus. 
There  is  no  danger  of  wounding  important  structures  if  the  incision 
follows  the  middle  line.  Leave  a  strip  of  gauze  in  the  wound  for 
drainage.  Prescribe  frequent  antiseptic  mouth-washes.  If  the 
abscess  lies  under  the  tongue  and  points  do\\Tiward,  the  incision 
must  be  made  along  the  floor  of  the  mouth,  if  the  mouth  can  be 
sufl&ciently  opened  and  fluctuation  detected.  The  ranine  artery 
may  be  wounded.  If  the  mouth  cannot  be  opened  it  is  best  to 
operate  from  the  outside,  making  a  median  vertical  incision  from 
the  symphysis  of  the  chin  down,  getting  between  the  two  genio- 
hyo-glossi  muscles  and  following  this  crevice  up  to  the  under  surface 
of  the  tongue.     Drainage-tube,  antiseptic  absorbent  dressing. 

TONSILLAR  ABSCESS 

''Quinsy"  is  an  actue  suppuration  in  the  tonsil  or  around  the 
tonsil  following  acute  infection  of  the  gland. 

Often  the  suppuration  occurs  only  on  one  side,  though  both 
tonsils  are  inflamed.  At  any  rate  the  two  tonsils  do  not  suppurate 
simultaneously. 

The  temperature  is  high,  the  pain  extreme,  there  is  difiiculty  in 
swallowing  and  perhaps  in  breathing.  There  may  be  edema  of  the 
glottis.  Often  there  is  difiiculty  in  opening  the  jaws.  After  the 
abscess  is  well  formed,  the  soft  palate  is  edematous  and  swollen. 


TONSILLAR   ABSCESS 


389 


Pus  begins  lo  form  about  the  third  day  after  the  attack.  Pre- 
vious to  this  an  effort  should  be  made  to  abort  the  abscess.  Give 
calomel  in  small  frequent  doses  and  follow  with  a  saline  purge, 
and  in  the  meantime  administer  full  doses  of  sodium  salicylate. 
Phenacetine,  2  or  3  grains  frequently,  will  make  the  patient 
more  comfortable.  Paint  the  tonsils  and  pharynx  with  argyrol 
once  a  day  and  use  the  peroxide  spray  (50  per  cent,  solution)  every 
two  or  three  hours.  Apply  hot  anti- 
septic fomentations  or  poultices  exter- 
nally. 

If  these  measures  fail  to  relieve  the 
symptoms  after  the  third  day,  it  is 
almost  certain  that  pus  has  formed, 
even  though  fluctuation  cannot  be 
felt,  and  it  is  best  to  make  an  incision, 
but  this  must  be  free. 

The  operation  is  sometimes  difficult. 
A  general  anesthesia  will  be  necessary 
if  the  jaws  are  locked.  Open  the 
mouth  wide.  A  mouth  gag  is  often 
necessary.  Depress  the  tongue  as 
much  as  possible.  Swab  the  tonsil 
with  a  10  per  cent,  solution  of  co- 
caine. With  a  sharp  pointed  bistoury 
(wrapped),    make    an    incision   in    the 

soft  palate  just  external  to,  and  parallel  with,  the  anterior  pillars 
and  extending  as  low  down  as  possible.  If  the  pus  flows  freely,  some 
of  it  may  be  swallowed,  to  prevent  which  bend  the  head  down. 
Continue  the  spray  and  antiseptic  mouth-washes  for  a  few 
days.  Whether  pus  is  located  or  not,  free  incision  gives  great 
relief  (Fig.  304). 

RETROPHARYNGE.\L  ABSCESS 


Fig.  304. — Tonsillar  abscess.  In- 
cision should  extend  as  low  as  possi- 
ble.    {Veau.) 


These  conditions  are  treacherous  and  dangerous  because  (most 
frequent  in  infants)  they  may  be  overlooked  and,  bursting  into  the 
pharynx,  may  produce  sufl'ocation. 

The  pharynx  is  separated  from  the  muscles  covering  the  anterior 


390  ABSCESS 

surface  of  the  bodies  of  the  cervical  vertebrae  by  a  loose  connective 
tissue.  One  or  two  lymphatic  glands  lie  in  front  of  the  bodies  of  the 
upper  two  cervical  vertebrae  on  either  side  of  the  middle  line.  These 
receive  lymph  (and  infection)  from  the  nasal  cavities  and  their 
accessory  sinuses,  the  naso-pharynx,  the  Eustachian  tube,  the  tym- 
panum, and  from  the  tissues  lying  on  the  bodies  of  the  adjacent 
vertebrae.  Septic  conditions  existing  in  any  of  these  locaUties  may 
be  the  source  of  the  inflammation  of  these  lymph  glands,  which  may 
end  in  suppuration.  These  glands  empty  by  several  chains  of  lymph 
vessels  into  the  deep  cervical  glands. 

The  suppuration  begins  on  one  side  usually,  but  rapidly  spreads 
toward  the  middle  line,  where  the  tissues  are  loosest.  The  abscess 
may  be  behind  the  palate;  it  maybe  opposite  the  larynx;  in  either 
case  almost  out  of  sight.  Usually,  however,  it  is  seated  in  the  pos- 
terior wall  of  the  pharynx,  opposite  the  oral  cavity.  When  situated 
there,  it  gives  rise  to  fewest  symptoms,  and  for  that  reason  its  de- 
velopment is  insidious,  and  in  the  infant  unsuspected.  The  con- 
stitutional disturbance  may  be  slight. 

Obstructed  breathing  and  hoarseness  and  a  feeling  of  tightness 
in  the  throat  may  first  suggest  the  difficulty.  Inspection  and 
palpation,  always  necessary,  are  not  always  easy  and,  in  the  case 
of  infants,  sometimes  dangerous.  Still,  only  by  touch,  with  the 
finger  in  the  mouth,  can  the  exact  condition  be  determined.  To 
prevent  asphyxia  or  syncope,  the  main  thing  is  to  be  rapid  in  the 
examination.     To  facilitate  this,  the  child  must  be  prepared. 

It  is  seated  on  the  assistant's  lap  with  its  face  turned  to  the  light, 
its  arms  and  body  encircled  by  a  towel,  its  legs  held  firmly  between 
the  assistant's  knees.  Its  mouth  is  forced  open  by  pressing  the 
cheeks  between  the  teeth.  The  finger  is  passed  to  the  back  of  the 
tongue  and  rapidly  palpates  the  walls  of  the  pharynx.  It  is  not 
difficult  to  determine  the  point  of  greatest  swelling. 

Operation. — i.  Have  already  prepared  a  sharp-pointed  bistoury 
wrapped  with  cotton  close  up  to  the  point.  The  index  finger  in 
the  mouth  holds  the  tongue  down  and  the  bistoury  is  passed  along 
the  finger  and  plunged  into  the  abscess  in  the  middle  line,  that  no 
blood  vessels  may  be  injured.  This  puncture  is  prolonged  into  an 
incision  from  above  downward  at  least  an  inch;  in  fact,  as  low  as 


RETROPHARYNGEAL   ABSCESS 


391 


possible,  that  chances  of  a  recurrence  may  be  diminished.  The 
patient  is  immediately  inclined  forward  in  order  that  the  pus  may 
pour  out  of  the  mouth  (Fig.  305). 

If  syncope  or  spasm  of  the  larynx  occurs,  do  not  lose  your  head, 
but  proceed  hastily  to  revive  the  patient  by  the  ordinary  means. 
Lower  the  patient's  head,  pull  out  the  tongue,  and  employ  artificial 
respiration. 

/ 


Pig.  305. — Retropharyngeal  abscess,     {Veau.) 


As  after-treatment,  direct  frequent  irrigations  or  gargling  with 
sterilized  water.  A  peroxide  spray  may  be  used  with  good  effect. 
Recovery  occurs  within  a  few  days. 

If  the  abscess  recurs,  or  in  the  first  place  is  situated  too  far  down 
for  oral  puncture  (which  may  sometimes  be  done  by  passing  a 
curved  director  over  the  base  of  the  tongue  and  then  downward  to 
the  top  of  the  abscess),  or  the  jaws  are  locked,  it  will  have  to  be 
reached  from  the  side  of  the  neck,  an  operation  much  more  difficult 
in  every  way. 

Operation. — 2.  Turn  the  patient  slightly  to  one  side,  resting  the 
neck  upon  a  cushion  to  make  its  lateral  aspect  prominent;  the  sterno- 


392  ABSCESS 

mastoid  is  the  guide.  Make  an  incision  about  2  inches  in  length 
along  the  posterior  border  of  the  sterno-cleido-mastoid,  which  is 
exposed  after  the  skin  and  fascia  are  divided.  Ligate  the  veins; 
avoid  the  superficial  cervical  nerves;  pull  the  sterno-cleido-mastoid 
forward  and  locate  the  scalenus  anticus.  Stick  to  the  scalenus 
anticus,  follow  its  anterior  surface  inward,  displacing  forward  by 
careful  dissection  with  grooved  director,  the  common  sheath  of  the 
great  vessels  and  pneumogastric.  The  connective  tissues  are  rather 
loose;  the  dissection  is  not  difficult.  Be  on  the  watch  for  the  spina^l 
accessory  nerve,  which  lies  on  the  deep  surface  of  the  sterno-mastoid. 
Working  inward  in  this  manner  reach  the  outer  border  of  the  longus 
colli  which  lies  in  the  same  plane  as  the  scalenus  anticus,  and  upon 
which  lies  the  pharynx  and  the  abscess.  After  opening  and  empty- 
ing, a  drain  must  be  left.  Employ  the  usual  dressings  and  after- 
treatment.  Sometimes  the  abscess  lies  further  forward  and  it  will 
be  necessary  to  go  in  front  of  the  sterno-cleido-mastoid.  After  the 
skin  and  fascia  are  divided,  the  finger  in  the  wound  will  be  able  to 
locate  fluctuation  and  that  will  be  the  best  guide  in  the  subsequent 
dissection.  It  may  be  necessary  to  ligate  several  small  veins.  Re- 
tract the  anterior  border  of  the  sterno-mastoid  and  with  it  the 
sheath  of  the  common  carotid,  the  internal  jugular  and  pneumo- 
gastric; draw  foward  the  thyroid,  the  larynx  and  trachea.  The 
fascias  are  divided  by  blunt  dissection  until  the  abscess  cavity  is 
opened. 

ABSCESS  OF  THE  GLANDS  OF  THE  NECK 

Acute  suppuration  of  the  lymph  glands  of  the  neck  is  quite  fre- 
quent and  originates  in  infective  disorders  of  the  areas  drained  by 
the  glands. 

In  treating  these  conditions,  the  source  of  the  infection  must  not 
be  overlooked.  It  is  not  always  advisable  to  operate  immediately, 
even  though  suppuration  is  believed  to  be  present,  unless,  of  course, 
the  infection  shows  a  tendency  to  become  general. 

In  the  ordinary  case,  the  pus  may  be  very  deeply  located  or  out- 
side the  capsule  of  the  gland.  It  is  better  under  these  circumstances 
to  apply  hot  antiseptic  poultices  for  twenty-four  to  forty-eight 
hours.     The  whole  gland  then  becomes  softened,  the  pus  is  easily 


MAMMARY   ABSCESS  393 

evacuated  and  healing  occurs  rapidly;  whereas  a  non-suppurating 
gland  cut  into  may  remain  enlarged  and  indurated.  Free  incision 
is  always  out  of  the  question  as  the  many  important  structures  of 
the  neck  have  to  be  borne  in  mind.  Use  local  anesthesia.  In  mak- 
ing the  incision  it  is  usually  best  to  follow  the  posterior  border  of 
the  sterno-mastoid.  Make  an  incision  about  2  inches  in  length. 
When  the  muscle  is  reached,  draw  it  forward  with  a  retractor  and 
with  a  grooved  director  search  for  the  pus  cavity ;  drain;  use  absorbent 
dressings. 

CHRONIC    SUPPURATION   OF   THE    CERVICAL   GLANDS 

There  are  various  clinical  manifestations  of  the  tubercular  proc- 
esses, each  of  which  demands  a  somewhat  different  treatment.  It  is 
assumed  that  the  pus,  gradually  accumulating,  has  burst  through 
the  fascia  and  has  begun  to  bulge  the  skin. 

It  is  best  to  operate  at  once.  The  most  careful  asepsis  should  be 
maintained.  The  pus  is  evacuated  by  free  incision  and  the  abscess 
cavity  wiped  out  with  iodoform  gauze.  A  10  per  cent,  solution  of 
iodoform  emulsion  with  glycerine  is  poured  into  the  cavity  (2  or 
3  drams  are  sufficient)  and  the  wound  sutured  and  treated  as 
an  aseptic  wound,  provided  there  is  no  evidence  of  secondary 
infection. 

ABSCESS  OF  THE  BREAST 

Abscess  of  the  breast  may  be  either  parenchymatous,  originating 
in  the  substance  of  the  gland;  or  submammary,  originating  in  the 
areolar  tissues  separating  the  gland  from  the  pectoralis  major. 

In  either  case  infection  nearly  always  begins  at  the  nipple  and 
follows  the  lymph  vessels  downward.  The  first  form  is  usually  due 
to  staphylococcic  infection,  the  second  to  streptococcic.  These 
conditions  are  preventable  in  the  greater  number  of  cases  and  for 
that  reason  the  nipple  should  be  given  special  care  both  before 
confinement  and  during  the  first  weeks  of  lactation. 

Even  when  the  breast  becomes  "caked"  and  tender  and  there  is  a 
little  fever,  antisepsis  at  the  nipple  and  hot  antiseptic  poultices  to 
the  breast  may  prevent  abscess  formation.     Continued  rise  in  tem- 


394  ABSCESS 

perature,  slight  chills,  edema  and  pain,  more  or  less  localized,  indi- 
cate the  formation  of  pus,  and  immediate  operation  is  necessary. 
A  general  anesthesia  is  best  for  thoroughness,  though  the  work  may 
be  done  under  local  anesthesia. 

Under  rigid  asepsis,  proceed  to  open  up  the  cavity,  and  always 
remember,  the  earlier  the  better.  An  incision  an  inch  or  so  long 
should  begin  near  the  nipple  and  radiate  from  it,  as  the  spoke  from 
the  hub  of  a  wheel.  In  this  manner  the  least  possible  number  of 
the  milk  ducts  and  vessels  are  divided  (Fig.  306). 


Fig,  306. — Abscess  of  the  breast:  incision.     (Lejars.) 

The  first  incision  goes  through  the  skin  and  fascia  and  then  the 
abscess  cavity  is  sought  for  by  blunt  dissection  with  a  grooved 
director.  Still  there  is  nothing  to  fear  in  cutting  boldly  down  to  the 
abscess.  Explore  the  cavity  thoroughly  for  there  may  be  pockets 
leading  off  from  the  main  cavity.  Do  not  neglect  this  point.  If  it 
extends  deep,  make  a  counter-opening  at  the  base,  being  guided  by 
the  director  introduced  through  the  first  opening  (Fig.  307).  Push- 
ing a  forceps  through  the  channel,  it  seizes  a  drainage-tube  which  is 
drawn  into  place  as  the  forceps  is  withdrawn.  Dress  with  anti- 
septic gauze,  which  should  be  changed  twice  daily  at  first,  care 
being  taken  not  to  disturb  the  drainage-tube. 

If  the  temperature  rises  again  after  the  second  or  third  day,  you 


AXILLARY    ABSCESS 


395 


will  have  to  re-explore.  A  new  abscess  is  in  process  of  formation. 
After  live  or  six  days  replace  the  first  drainage-tube  with  a  smaller 
one.  The  drainage-tube  can  be  entirely  dispensed  with  after  ten 
days  or  two  weeks. 

The  submammary  abscess  develops  without  edema  or  redness 
because  it  underlies  the  whole  breast.  The  condition  can  scarcely 
be  mistaken,  for  the  marked  elevation  of  the  whole  breast,  along  with 
the  constitutional  symptoms  point  to  the  nature  of  the  trouble. 
Make  a  curved  incision  following  the  base  of  the  breast  at  its  lowest 


D 


Fig.  307, — Abscess  of   the  breast.      Manner  of   making  counter-opening.     D,  grooved  di- 
rector; P,  its  point;  B,  bistoury  cutting  down  on  to  the  point  of  director.     (Lejars.) 

part,  dividing  the  skin  and  fascia.  With  a  grooved  director,  dissect 
through  the  areolar  tissues  between  the  gland  and  the  chest  wall, 
working  toward  the  center  of  the  breast.  These  deep  tissues  are 
likely  to  be  infiltrated.  In  this  manner  the  pus  is  evacuated  and 
the  subsequent  treatment  will  be  practically  the  same  as  that 
prescribed  for  the  preceding  form. 


AXILLARY  ABSCESS 

Three  chains  of  lymphatic  glands  are  found  in  the  axillary  space. 
One  lies  along  the  anterior  fold  of  the  axilla  and  drains  the  anterior 


396 


ABSCESS 


thoracic  region;  one  lies  on  the  posterior  axillary  wall  and  drains  the 
posterior  thoracic  region;  one  lies  alongside  and  externally  is  con- 
nected with  the  axillary  vessels  and  drains  the  upper  extremity. 
Axillary  abscess  usually  results  from  inflammation  of  one  or  the  other 
of  these  chains  of  glands,  the  infective  agent  having  been  carried 
to  them  from  a  distant  point,  such  as  the  breast  or  hand,  by  the 
lymph  vessels. 

The  inflammation  spreads  from  the  glands  to  the  adjacent  areolar 
tissue  and  pus  formation  follows.  Abscess  may  also  form  by  exten- 
sion of  pus  formation  from  the  base  of  the  neck. 


Fig,    308. — Cross   section    showing    relations   of   axillary   abscess.     G.   F.    Pect.    major. 
P.P.   Pect.    minor.     G.    D.   Latiss,    dorsi.    S.SC.    Subscapularis.     G.    D.    Serratus   magnus. 

(FcflM.) 

The  most  frequent  sources  of  infection,  probably,  are  the  breast 
and  the  sebaceous  glands  in  the  skin  of  the  armpit.  Abrasions  and 
small  boils  in  this  locality  must  be  treated  with  circumspection,  lest 
they  terminate  finally  in  axiflary  abscess.  The  ordinary  symptoms 
of  inflammation  and  pus  formation,  added  to  the  painful  abduction 
of  the  arm,  indicate  the  nature  of  the  trouble. 

It  is  imperative  to  evacuate  the  pus  promptly  for  the  reason  that 
it  may  burrow  in  various  directions,  usually  upward  toward  the  neck. 
The  axillary  vessels  may  be  eroded. 

The  incision  will  depend  upon  the  location  of  the  pus — that  is  to 


AXILLARY    ABSCESS 


397 


say,  whether  it  lies  under  the  pectoralis  major  or  in  the  loose  areolar 
tissues  of  the  center  of  the  space.  Acute  abscess  more  often  lies 
in  the  first  locality  (Fig.  308) ;  tubercular  abscess  in  the  latter. 

(a)  Acute  Abscess  (Fig.  309). — General  anesthesia;  place  the 
patient  on  his  back;  abduct  the  arm  as  much  as  possible;  and  locate 
the  border  of  the  pectoralis  major.  Make  an  incision  3  inches 
in  length  along  this  line,  cutting  toward  the  thorax;  expose  the 
muscle  border  well;  dissect  along  the  under  surface  of  the  pectoralis 
major  with  the  grooved  director.  In  this  manner  you  keep  in  front 
of  the  great  vessels  and  nerves  and  will  feel  secure.  When  the  pus 
once  flows,  enlarge  the  opening,  and  insert  drainage-tubes. 


Pig.  309. — Incision  for  acute   axillary    abscess.     The  blunt  dissection  should  follow 
the  anterior  axillary  wall.      (Veau.) 


To  avoid  the  axillary  structures,  you  must  keep  these  two  points 
in  mind:  (i)  Make  the  opening  large  enough  to  see  what  you  are 
doing — a  blind  stab  in  this  region  is  exceedingly  dangerous;  (2) 
stick  to  the  pectoralis  major — the  pus  is  in  contact  with  its  deep 
surface.  Wash  out  the  cavity  and  place  two  drains;  use  a  gauze  and 
absorbent  cotton  dressing  daily  for  a  week,  after  which  remove  the 
tubes,  though  the  external  opening  must  not  be  allowed  to  close  until 
the  cavity  is  eliminated. 

(b)  Chronic  Abscess. — Incision.  Begin  in  the  middle  of  the  floor 
of  the  space  and  follow  the  middle  line  away  from  the  arm  toward 


398  ABSCESS 

the  chest.  In  this  direction  alone  is  safety.  In  front  are  the  long 
thoracic  vessels;  behind  are  the  subscapular  vessels;  to  the  outside 
are  the  main  axillary  vessels  and  branches  of  the  brachial  plexus. 
The  skin  incision  may  occasionally  divide  a  small  artery,  which  will 
at  first  give  some  concern.  It  is  best  to  divide  the  connective  tissues 
layer  by  layer  in  the  original  line  of  incision.  There  is  no  danger 
if  you  keep  in  this  line.  Otherwise,  the  pus  may  be  reached  by 
Hilton's  method.  After  the  skin  and  fascia  are  divided,  a  dressing 
forceps  is  pushed  up  into  the  abscess  cavity  and  the  bladeso  pened. 
Put  in  a  drainage-tube;  use  absorbent  dressings;  maintain  a  careful 
asepsis  throughout  the  process  of  repair. 

PALMAR  ABSCESS 

These  are  always  serious  conditions,  not  alone  on  account  of  sepsis, 
but  because  the  hand  may  be  left  permanently  crippled  or  useless  as 
a  result  of  the  destruction  of  tissue  and  inflammatory  adhesions. 

Immediate  evacuation  of  pus  is  imperative.  If  the  pus  is  limited 
to  the  connective  tissues  of  the  palm,  has  not  reached  the  tendon 
sheaths,  the  incision  should  be  made  over,  and  parallel  with,  the 
interosseous  space  in  the  region  of  the  greatest  swelling. 

If  the  tendon  sheaths  are  involved,  the  incision  should  be  made  in 
the  long  axis  of  the  metacarpal  bone  (see  Phlegmon,  page  424). 
Whether  the  condition  is  a  diffuse  inflammation  (phlegmon)  or  an 
abscess  will  be  determined  by  the  history  of  the  case. 

In  the  case  of  abscess,  make  a  longitudinal  incision.  The  palmar 
arches  are  chiefly  to  be  considered.  Begin  the  incision  just  below  a 
line  drawn  across  the  palm  from  the  web  of  the  thumb.  Beginning 
nearer  the  wrist,  the  superficial  palmar  arch  or  the  deep  arch  as  well 
may  be  divided.  Cut  toward  the  finger,  making  the  incision  suffi- 
ciently deep  to  go  quite  through  the  palmar  fascia.  Insert  a  drain- 
age-tube. Use  antiseptic  dressings,  changing  the  dressings  daily. 
(See  also  Phlegmons.) 

POPLITEAL  ABSCESS 

Situated  in  the  hollow  back  of  the  knee-joint  in  the  superficial 
fascia  are  a  few  lymph  glands  which  may  suppurate  following  an  in- 


POPLITEAL   ABSCESS  399 

fective  process  in  the  fool  or  leg.  Situated  still  deeper  ])eneath  the 
deep  fascia  are  other  glands  which  may  similarly  suppurate. 

These  may  be  described,  then,  as  superficial  abscess  and  deep 
abscess  of  the  popliteal  space. 

The  superficial  abscess  may  be  opened  simply  by  a  vertical  in- 
cision over  the  point  of  greatest  swelling.  There  are  no  important 
structures  likely  to  be  wounded  by  a  superficial  incision. 

It  is  quite  different  with  a  deep  abscess.  The  situation  of  a  number 
of  important  structures  must  be  borne  in  mind.  In  the  center  of 
the  lower  half  of  the  space  lies  the  short  saphenous  vein;  to  the 
outer  side  lies  the  external  popliteal  nerve,  and  running  vertically 
through  the  center  of  the  space,  and  deeply  located,  are  the  popliteal 
vessels  and  internal  popliteal  nerve.  The  space  is  roofed  over  by 
the  dense  popliteal  fascia  which  is  the  chief  factor  in  determining  the 
direction  in  W'hich  the  suppuration  extends;  thus  the  pus  is  more 
likely  to  point  up  in  the  thigh  or  down  in  the  leg  than  in  the  integu- 
ments of  the  space. 

A  popliteal  abscess  may  likewise  be  the  result  of  the  extension  of 
a  suppurative  process  in  the  thigh.  These  abscesses  must  be  opened 
without  delay  for  the  reason  that  the  joint  may  become  involved,  the 
vessels  may  slough,  and  there  may  be  destruction  of  tissue.  There 
may  be  permanent  flexion  of  the  leg  due  to  scar  tissue. 

Before  opening  a  popliteal  abscess  the  diagnosis  must  be  con- 
firmed. It  has  happened  more  than  once  that  a  popliteal  aneurism 
has  been  mistaken  for  an  abscess  and  incised,  a  mistake  serious  indeed 
for  both  patient  and  operator. 

Acute  inflammation  of  the  bursae  must  not  be  mistaken  for  ab- 
scess. These  bursae  are  found  in  the  boundaries  of  the  space, 
separating  the  tendons  from  the  protuberances  of  the  femur,  tibia, 
and  fibula. 

Operation. — Either  general  or  local  anesthesia  may  be  used.  Make 
a  vertical  incision  in  the  center  of  the  space,  dividing  the  skin,  the 
superficial  fascia,  and  the  deep  fascia  successively.  With  the  grooved 
director  separate  the  fatty  tissues  filling  the  space;  keep  in  the  line 
of  the  original  incision.  The  pus  will  usually  be  located  before  the 
depth  of  the  vessels  has  been  reached.  Enlarge  the  opening  in  the 
connective  tissues,  irrigate,  search  for  diverticula,  insert  a  drainage- 


400  ABSCESS 

tube  and  pack  lightly  around  the  tube  with  aseptic  gauze.  Apply 
absorbent  dressings  and  extend  the  leg  on  a  posterior  splint.  This 
extension  must  be  maintained  until  the  healing  is  complete  to  prevent 
flexion. 

PLANTAR  ABSCESS 

The  deep  fascia  of  the  sole  of  the  foot  is  especially  developed.  It 
extends  as  a  broad,  dense  band  from  one  end  of  the  plantar  arch  to 
the  other,  from  the  os  calcis  to  the  base  of  the  metatarsal  bones. 
It  is  a  broad  band  divided  into  three  portions:  outer,  middle,  and 
inner.  The  central  portion  alone  is  of  much  surgical  importance. 
Its  anterior  extremity  is  broken  up  into  five  slips,  and  each  slip 
branches  and  forms  an  arch  for  a  flexor  tendon. 

The  result  of  this  arrangement  is  that  here  is  a  closed  compartment 
between  the  fascia  and  the  bones  of  the  foot  which  is  occupied  by 
the  muscles  of  the  middle  foot.  Following  an  infection,  pus  form- 
ing in  this  compartment  finds  great  difficulty  in  escaping.  It 
burrows  between  the  metatarsal  bones  and  makes  its  appearance 
on  the  dorsum  of  the  foot,  follows  the  flexor  tendons  backward  to 
the  inner  ankle,  or  may  escape  through  the  small  aperture  for  the 
arteries  into  the  subcutaneous  fascia. 

On  account  of  the  denseness  of  the  fascia,  the  pain  in  plantar  ab- 
scess is  extreme,  and  for  relief  of  this  pain  and  to  prevent  destruc- 
tion of  tissue,  an  early  incision  is  imperative.  The  incision  should 
be  made  over  the  most  prominent  part  of  the  swelling,  its  direction 
corresponding  to  the  long  axis  of  the  foot. 

The  skin  is  divided  and  then  the  thick  fatty  tissues,  until  the  white 
and  firm  plantar  fascia  is  reached.  After  the  fascia  is  divided, 
the  dissection  is  completed  with  a  grooved  director  until  the  pus 
cavity  is  located.  In  this  manner  no  important  structures  are 
wounded.  Wash  out  the  cavity  and  insert  a  small  drainage-tube. 
It  is  important  that  the  cavity  heal  from  the  bottom. 

ISCHIO-RECTAL  ABSCESS 

The  ischio-rectal  fossa  is  a  wedge-shaped  cavity,  lying  on  either 
side  of  the  rectum,  between  it  and  the  pelvic  wall.     Its  base  is 


ISCHIO-RECTAL   ABSCESS  401 

covered  by  the  inlegument  and  its  sharp  edge  is  directed  upward 
and  corresponds  to  a  line  drawn  from  the  pubes  backward  to  the 
spine  of  the  ischium — the  line  of  attachment  of  the  levator  ani 
muscle,  the  ''white  line"  of  the  pelvic  fascia.  The  levator  ani  mus- 
cle forms  its  inner  boundary.  The  obturator  fascia  covering  the 
bony  pelvic  wall  forms  its  outer  boundary. 

The  fossa  is  hlled  with  fatty  tissue  which  seems  to  form  a  packing 
and  support  for  the  rectum,  but  which  at  the  same  time  forms  a 
site  of  ''lowered  resistance"  to  infective  agents. 

These  infective  agents  gain  access  to  the  fatty  tissues  of  the  fossa 
through  ulcerations  or  abrasions  of  the  rectal  mucous  membrane  or 
from  similar  conditions  in  the  integument  around  the  anal  orifice. 
For  the  most  part  the  bacteria  follow  the  lymphatics  which  have 
their  origin  in  these  localities  and  which  follow  the  branches  of  the 
inferior  hemorrhoidal  vessels  through  the  fossa.  The  abscess  may 
be  secondary  to  prostatic  abscess. 

The  symptoms  of  acute  abscess  here  are  the  ordinary  constitutional 
symptoms  in  marked  degree,  accompanied  by  intense  throbbing 
pain  in  the  region  of  the  anus.  The  skin  becomes  brawny  and 
indurated  but  no  fluctuation  appears  in  many  cases. 

The  symptoms  of  chronic  abscess  differ  only  in  degree,  and  are 
often  so  slight  as  to  be  entirely  overlooked.  Abscess  of  any  kind  in 
this  locality,  when  diagnosed,  should  be  evacuated  without  delay. 
If  let  alone  it  will  eventually  open  the  rectum  or  through  the  skin 
if  the  patient  should  survive  the  general  sepsis.  But  spontaneous 
evacuation  is  in  every  way  to  be  avoided,  if  possible.  A  fistula  is 
the  inevitable  sequel  if  the  case  is  left  to  nature. 

This  fistula,  opening  into  the  bowel  whether  the  abscess  formed 
near  the  roof  of  the  fossa  or  near  the  floor,  is  very  likely  to  be  just 
above  the  external  sphincter.  There  the  bowel  wall  is  thinnest, 
and  the  f ascias  of  the  levator  ani  act  as  an  inclined  plane  along  which 
the  pus  moves  toward  that  part  of  the  bowel. 

The  examining  finger  in  the  rectum  in  the  case  of  abscess  will 
nearly  always  detect  the  threatened  opening  there  and  confirm  the 
diagnosis. 

Operation. — General  anesthesia;  lithotomy  position;  antisepsis. 

The  incision  (Fig.  311),  4  or  5  inches  in  length,  is  made  from 
26 


402 


.\BSCESS 


before  backward  and  inclined  a  little  outward  midway  between  the 
ischial  tuberosity  and  the  rectum.  Remember  that  cutting  too 
near  the  middle  line,  you  may  wound  the  rectum;  too  near  the  pelvic 
wall,  you  may  wound  the  internal  pudic  vessels.  Some  small 
hemorrhage  \\dll  follow  the  skin  incision.  It  may  be  necessary  to 
cut  deeper  along  the  same  line  and  you  may  wound  some  of  the 
branches  of  the  inferior  hemorrhoidal  arteries,  but  that  is  not  a  seri- 
ous matter. 

With  a  little  patience,  in  this  manner  the  pus  is  reached  and  it 
pours  out,  extremely  fetid  and  often  mixed  with  shreds  of  con- 
nective tissue; 


Fig.  311. — Ischio-rectal  abscess.     Incision.     {Veau.) 

Enlarge  the  wound  so  that  it  may  be  inspected  and  explore  it 
with  the  finger.  Irrigate  vigorously.  Being  assured  that  all  the 
minor  cavities  are  opened  up,  introduce  a  large  drainage-tube  and 
pack  around  it  with  gauze.  The  dressing  must  be  renewed  daily 
at  first.     The  tubes  can  be  gradually  withdraw^n. 

It  is  absolutely  necessary  that  the  wound  heal  by  granulation  from 
the  bottom  and  this  may  be  a  matter  of  weeks  or  even  months.  Of 
this  the  patient  should  always  be  forewarned.  During  this  time 
the  dressings  must  be  carried  out  methodically.  Often  following 
incision  and  drainage  there  is  a  tendency  to  relapse  because  the 
primary  focus  of  suppuration  in  the  prostate  has  not  been  recog- 
nized and  reheved. 

If  a  small  opening  is  exposed  high  up  in  the  cavity,  through  which 
pus  drains,  it  indicates  a  peri-rectal  abscess  above  the  levator  ani, 


PERI-ANAL   ABSCESS  403 

dangerous  because  it  may  become  a  general  pelvic  cellulitis  or 
peritonitis.  Enlarge  the  opening  by  the  introduction  of  a  dressing 
forceps,  irrigate  and  drain. 

These  peri-rectal  abscesses  not  involving  the  ischio-rectal  fossa  are 
difficult  to  diagnosticate,  but  when  once  determined  they  must  be 
opened  in  the  manner  already  indicated. 

Again,  the  ischio-rectal  abscess  may  have,  unfortunately,  already 
opened  through  the  rectal  wall.  Make  the  skin  incision  as  before, 
and  then  an  additional  step  is  necessary.  Push  a  grooved  director 
up  through  the  abscess  cavity  and  through  the  rectal  opening  and 
then,  following  along  the  grooved  director,  cut  through  the  entire 
thickness  of  the  rectal  and  anal  walls,  holding  one  finger  in  the 
rectum  to  guide  the  knife.  It  will  look  like  a  very  long  wound,  and 
yet  it  has  the  excellence  of  favoring  recovery  and  of  preventing  a 
fistula.  However,  under  the  most  favorable  circumstances,  it  may 
require  several  months  to  heal  (Lejars). 

PERI-AN.\L  ABSCESS 

These  are  much  less  serious  than  those  of  the  ischio-rectal  region, 
both  with  regard  to  prognosis  and  treatment.  However,  if  neg- 
lected, they  are  likely  to  result  in  fistula;  even  if  not  properly  in- 
cised they  may  so  result.  The  peri-anal  abscess  is  in  the  glands 
surrounding  the  anal  margin  and  lies  under  the  integument  or 
mucous  membrane.  Local  anesthesia  is  all  that  is  necessary  except 
for  those  who  are  timid,  and  with  them  general  anesthesia  is 
indispensable. 

Puncture  the  tumor  at  its  apex.  The  pus  is  foul  smelling.  Irri- 
gate; explore  the  cavity  methodically  with  a  grooved  director. 
There  is  nearly  always  an  ascending  diverticulum  on  the  anal  side 
which  communicates  with  the  rectum.  Having  located  the  apex 
of  the  cavity,  push  the  point  of  the  director  through  the  mucous 
membrane;  in  other  words,  make  a  fistula  if  one  does  not  already 
exist  (Fig.  312).  Divide  all  the  tissues  over  the  director,  in  this 
manner  laying  open  the  cavity  and  anal  margin.  Carefully  wipe 
out  the  walls  of  the  abscess  and  pack  with  iodoform  gauze.  As 
important  as  the  operation  is  the  after-treatment.     This  the  doctor 


404 


ABSCESS 


must  attend  to  himself.  The  dressing  must  be  made  daily,  washing 
and  packing  lightly.  After  each  movement  of  the  bowels,  the 
wound  must  be  washed  and  the  packing  replaced,  if  possible.  It 
is  essential  that  the  cavity  granulate  from  the  bottom.  Repress 
excessive  granulation  with  tincture  iodine. 


Fig.  312. — Incision  for  peri-anal  abscess.      (Veau.) 


PROSTATIC  ABSCESS 

The  prostate  gland,  about  the  size  and  shape  of  a  chestnut,  lies 
at  the  base  of  the  bladder,  clasping  but  not  quite  encircling  the  first 
portion  of  the  urethra.  The  upper  surface  of  the  urethra  is  covered 
by  fibrous  tissues  which  connect  the  upper  surface  of  the  two  lateral 
halves  of  the  prostate,  so  that  the  urethra  apparently  makes  a 
tunnel  through  the  prostate.  The  ejaculatory  ducts  empty  into 
this  portion  of  the  urethra. 

The  prostate  is  in  contact  with  the  second  portion  of  the  rectum 
1 3-^  to  2  inches  from  the  anal  orifice.  The  apex  rests  against 
the  triangular  ligament,  which  separates  it  from  the  bulb  of  the 
urethra. 

Suppurative  inflammation  in  the  prostate  originates  from  infec- 
tion caught  up  by  the  lymphatics  of  the  prostatic  and  membranous 
portions  of  the  urethra.  These  infective  agents  are  the  gonococci, 
staphylococci,  streptococci,  bacilli  coli  communis. 

As  might  be  expected,  gonorrhea  is  the  most  frequent  cause,  both 
directly  and  indirectly.     The  passage  of  sounds,  perineal  bruises, 


PROSTATIC   ABSCESS  405 

sexual  excesses,  and  lii^h  living  in  one  way  or  another  favor  the 
development  of  an  intlammatory  process  which  may  result  in 
abscess-formation. 

The  abscess  may  be  limited  to  the  gland  substance  or  may  develop 
in  the  connective  tissue  surrounding  the  gland.  In  this  case  it 
may  be  called  a  pelvic  abscess.  It  may  become  an  ischio-rectal 
abscess. 

Chronic  prostatic  abscess  may  be  overlooked  and  unrecognized 
as  the  direct  cause  of  many  conditions:  chronic  urethral  discharge; 
vesical  and  rectal  irritation;  rectal  fistula;  chronic  inflammation  of 
the  prostatic  adnexa  (the  ejaculatory  ducts  and  seminal  vesicles); 
suppurating  epididymitis  and  orchitis;  nocturnal  emissions. 

Any  abscess  of  the  prostate  may  open  into  the  rectum,  bladder, 
urethra,  perineum,  or  suprapubic  region.  Finally  there  is,  in  the 
case  of  actue  abscess,  the  imminent  danger  of  the  general  involve- 
ment of  the  pelvic  fascia,  ending  in  septicemia.  It  is  manifest  that 
a  prostatic  abscess  is  a  constant  menace.  Its  evacuation  must 
not  be  delayed.  It  cannot  be  denied  that  oftentimes  spontaneous 
evacuation  is  followed  by  a  complete  cure,  but  the  outlook  is  many 
times  more  favorable  with  immediate  operation.  Sometimes  the 
only  cure  is  in  complete  removal  of  the  gland. 

Diagnosis. — There  is  usually  a  history  of  gonorrhea,  recent  or  re- 
mote. Fever  and  a  few  chills;  violent  perineal  pain,  radiating  to  the 
rectum  and  thighs;  painful  and  difficult  urination  and  defecation 
point  to  probable  suppuration  in  the  prostatic  region.  A  little 
later  perhaps  the  perineum  is  reddened,  swollen,  and  infiltrated. 
Complete  the  diagnosis  by  introducing  a  well-oiled  finger  into  the 
rectum,  which  will  excite  much  pain.  On  the  anterior  wall  of  the 
rectum  wall  be  found  a  large  unsymmetrical  swelling,  more  or  less 
clearly  fluctuating,  and  which  loses  itself  in  a  doughy  tumor  extend- 
ing toward  the  sides  of  the  rectum  and  the  anus.  Now  must  one 
operate  even  though  there  be  some  pus  discharging  through  the 
urethra,  having  begun  spontaneously  or  following  the  passage  of  a 
catheter.     Such  drainage  is  quite  insufficient. 

There  are  two  methods  of  operation:  (a)  the  rectal  route  when 
the  abscess  is  about  to  burst  into  the  rectum;  (b)  the  perineal  route, 
under  all  other  conditions.     In  either  condition  general  anesthesia  is 


4o6 


ABSCESS 


indispensable.  The  perineum  and  its  vicinity  are  carefully  sterilized 
and  the  patient  placed  in  the  lithotomy  position  for  the  perineal 
incision. 

Rectal  route:  Place  the  patient  on  the  right  side,  flex  the  left  thigh 
on  the  abdomen  and  let  the  assistant  hold  up  the  left  buttock- 
Dilate  the  anus  and  give  the  rectal  mucosa  a  thorough  lavage,  wash- 
ing with  soap  and  water  and  gauze,  followed  by  an  alkaline  antiseptic 
solution. 

Retract  the  posterior  wall  of  the  rectum  with  a  Sims'  speculum. 
The  anterior  wall  will  thus  be  exposed  to  inspection.    Locate  hy 


Fig.  313, — Prostatic    abscess;    patient    in  lithotomy    position;    incision     between    bulb 
and  anus  extending  laterally  to  the  ischial  tuberosities.     {Veau  after  Pierre  Duval.) 


touch  the  thinnest  part  of  the  abscess  wall,  for  the  tumor  will  not  be 
so  conspicuous  to  sight  as  it  is  to  the  touch.  Without  hesitation 
push  the  point  of  the  knife  }^  inch  into  the  tumor.  This  is 
to  be  done  by  sight  and  not  by  touch.  When  the  pus  flows,  enlarge 
the  opening,  cutting  toward  the  anus.  Make  the  opening  at  least 
an  inch  in  length.  Favor  the  flow  by  slight  pressure,  and  finally 
irrigate.  You  may  be  satisfied  with  that,  leaving  no  drainage,  but 
repeating  the  rectal  flushing  several  times  daily  at  first.  If  the 
cavity  is  deep  and  if  there  is  considerable  oozing,  it  is  better  to 


PROSTATIC   ABSCESS 


407 


pack  very  lightly  with  aseptic  gauze,  which  will  be  expelled  with  the 
lirst  movement  of  the  bowels. 

Perineal  route:  An  incision  i  inch  in  front  of  the  anus,  transverse, 
slightly  curved  with  convexity  forward  (Fig.  313).  This  incision 
divides  the  skin  and  superficial  fascia — edematous,  it  may  be. 
Separate  the  edges  of  the  wound  and  identify,  if  possible,  the  muscu- 
lar layers  composed  of  the  transversus  perinei,  the  sphincter  ani  and 
accelerator  urinae,  which,  coming  from  the  cardinal  points,  meet  at 
the  "central  tendinous  point  of  the  perineum,"  which  is  to  be  next 


Fig.  314. — Prostatic  abscess.  Showing  relation  of  structures  concerned  in  operation; 
in  front  the  bulb  of  the  urethra,  on  either  side  of  the  erectors  of  the  penis,  transversely  the 
transversus  perinei  which  is  divided  parallel  with  its  fibers.     (Veau  after  Pierre  Duval.) 

incised.  If  these  structures  are  not  recognizable,  the  bulb  of  the 
urethra  covered  by  the  accelerator  urinae  can  at  least  be  found.  It 
is  a  prominence  which  the  finger  if  not  the  eye  will  readily  detect. 
Incise  transversely  through  the  middle  of  the  transverse  perinei 
(Fig.  314),  or  at  least  just  behind  the  bulb.  The  transversus  perinei 
artery  will  be  divided.  Now  draw  the  bulb  forward  out  of  the  way 
with  a  retractor  and  pull  the  posterior  Hp  backward  with  an  artery 
forceps. 

Make  the  third  transverse  incision  through  the  layer  now  well  ex- 


4o8 


ABSCESS 


posed,  viz.:  the  superficial  layer  of  the  triangular  ligament,  a  dense, 
fibrous  membrane.  The  abscess  is  now  covered  only  by  the  deep 
layer  of  the  triangular  ligament,  and  this  is  best  opened  up  with  the 
grooved  director,  working  forward  in  order  to  avoid  the  rectum, 
which  lies  immediately  behind  (Fig.  315). 

As  soon  as  the  cavity  is  located,  enlarge  the  opening  with  the 
forceps,  irrigate  gently,  place  a  drainage-tube  and  use  an  absorbent 
dressing,  which  is  to  be  removed  each  morning  and  evening  and  after 
stool. 


Fig.  315. — -Prostatic  abscess;  showing  relation  to  bladder  and  rectum  and  the  muscular  and 
fibrous  layers  to  be  divided.      {Veau.) 

Irrigation  and  Drainage  of  the  Seminal  Duct  and  Vesicle. — -Purulent 
accumulations  in  the  seminal  vesicles  demand  relief  on  account  of 
the  frequent  urination  and  other  symptoms  which  sometimes  may 
be  attributed  to  the  prostate  itself. 

Belfield,  of  Rush  Medical  College,  accomplishes  the  relief  of  these 
conditions  by  drainage  through  the  vas  deferens. 

The  vas  deferens  is  caught  between  the  fingers  at  the  base  of  the 
scrotum  and  brought  up  against  the  skin  and  held  by  a  half-curved 
needle  passed  through  the  skin  under  the  vas.  A  half-inch  incision 
under  local  anesthesia  is  then  made  over  the  vas;  it  is  exposed  and 


VULVAR    ABSCESS  409 

opened  by  a  longitudinal  or  transverse  incision.  The  l)lunted  needle 
of  a  hypodermic  syringe  is  then  passed  into  the  canal  and  the  solution 
injected.  The  liquid  traverses  the  vas  and  the  ampulla,  and  distends 
the  seminal  vesicles. 

If  necessary  the  vas  may  be  stitched  to  the  skin  by  a  fine  silk- 
worm-gut suture,  and  a  fistula  thus  established,  through  which 
daily  injections  may  be  made.  By  this  means,  too,  the  vas  is  made 
to  serve  as  a  drainage-tube  for  the  ampulla. 

A  fine  silkworm-gut  may  be  passed  into  the  canal  and  left  until  the 
next  injection.  Belfield  recommends  the  procedure  for  chronic 
gonorrheal  infections  of  the  seminal  canal;  chronic  pus  infections 
in  the  elderly  (often  mistaken  for  enlarged  prostate) ;  for  acute  gon- 
orrheal spermato -cystitis;  and  for  the  abortion  of  threatened 
epididymitis. 

VULVAR  ABSCESS 

The  labia  majoria  are  composed  of  areolar  and  fatty  tissues, 
bounded  on  one  side  by  skin  and  on  the  other  by  mucous  membrane. 
These  integuments  have  many  sebaceous  follicles  and  are  exposed 
to  various  forms  of  infection  and  traumatism.  Along  these  sebaceous 
follicles  and  the  lymphatics,  agents  of  suppuration  may  travel  to 
reach  the  areolar  tissues,  which  are  so  prone  to  yield  to  the 
attack. 

The  traumatisms  of  accident  and  brutality  and  excessive  coitus 
then  are  the  predisposing  causes;  the  streptococci  and  gonoccoci, 
•  the  specific  agents  of  inflammation  of  the  vulva,  which  may  end  in 
abscess.  The  suppuration  takes  on  the  diffuse  rather  than  the 
circumscribed  form.  The  labium  majus  of  the  affected  side  is 
swollen,  doughy,  reddened,  dry,  and  there  are  the  other  local  and 
constitutional  signs  of  suppuration.  The  skin,  apparently  more  than 
the  mucous  membrane,  is  involved  and  the  lesser  labium,  scarcely 
at  all.  In  order  to  avoid  general  infection,  or  an  ugly  slough  from 
spontaneous  evacuation,  the  abscess  must  be  incised  immediately. 
The  presence  of  pus  can  nearly  always  be  determined  by  fluctuation. 
After  careful  antiseptic  preparation,  a  vertical  incision  in  the  site 
of  the  greatest  sweUing,  usually  in  the  integument,  will  be  sufficient. 
There  are  no  vessels  to  fear.     Ordinarily,  a  strip  of  iodoform  gauze 


4IO 


ABSCESS 


will  furnish  sufficient  drainage.     An  absorbent  dressing  and   rest 
will  soon  bring  about  a  cure. 


VULVO-VAGINAL  ABSCESS.     (ABSCESS   OF  BARTHOLIN'S 

GLAND) 

Beneath  the  vaginal  mucous  membrane,  near  the  junction  of  the 
lateral  and  posterior  walls,  between  the  lesser  labium  in  front  and 
the  triangular  ligament  behind,  is  Bartholin's  gland,  one  on  each 

side.  The  gland  is  normally 
about  the  size  of  a  small  almond, 
and  is  about  i  or  ij^  inches  from 
the  vulvar  orifice.  Its  duct  opens 
into  the  vulvar  canal  just  exter- 
nal to  the  hymen  or  its  remains, 
the  carunculae  myrtiformes.  Its 
lymphatics  empty  into  the  super- 
ficial glands. 

Its  relation  of  greatest  surgical 
importance  is  with  the  venous 
plexus  (the  bulb  of  the  vagina), 
which  covers  its  upper  half  and 
which  may  be  wounded  by  too 
free  incision.  As  in  the  case  of 
vulvar  abscess,  the  cause  of  sup- 
puration is  an  infective  agent, 
most  frequently  the  gonococcus, 
which  reaches  the  gland  by  way 
of  the  excretory  duct.  Excessive 
coitus  is  a  predisposing  cause. 
The  symptoms  at  first  are  those 
of  acute  inflammation  of  the  vulva  or  vagina;  finally  the  symptoms 
become  localized. 

On  examination  the  vaginal  orifice  is  found  to  be  almost  closed 
on  account  of  the  swelling,  and  the  mucous  membranes  hot  and  dry. 
The  examining  finger  detects  on  the  affected  side  a  well-defined 
body  varying  in  size,  perhaps  no  larger  than  a  chestnut,  perhaps  as 


Fig.  316. — Vulvo- vaginal    abscess. 
Direction  of  incision. 


PELVIC  ABSCESS  411 

large  as  a  hen's  egg.  It  is  clearly  circumscribed.  The  labium 
majus  is  only  slightly  edematous  ordinarily,  the  lower  part  more  so. 
The  abscess  must  be  incised  as  soon  as  fluctuation  is  present  in  the 
slightest  degree.  Several  serious  consequences  may  attend  delay. 
The  inflammation  may  follow  the  vaginal  areolar  tissues  into  the 
pelvis;  there  may  develop  a  phlebitis,  or  sloughing  of  the  veins,  or 
lymphangitis,  or,  what  is  more  common,  there  may  result  a  recto- 
vaginal fistula. 

Operation. — -Cleanse  the  parts  carefully  under  local  or  general 
anesthesia,  incise  the  tumor  in  the  direction  of  the  long  axis  of  the 
vagina  from  within  outward  (Fig.  316).  Incise  thoroughly,  as  this 
is  the  means  of  securing  the  drainage  that  will  prevent  a  fistula.  The 
incision  must  not  be  deep  near  the  vaginal  orifice  for  fear  of  wound- 
ing the  bulb  of  the  vestibule.  A  strip  of  gauze  will  favor  healing 
from  the  bottom  of  the  abscess.  The  region  should  be  frequently 
douched. 

PELVIC  ABSCESS 

Separating  the  pelvic  peritoneum  from  the  organs  of  this  region 
are  loose  areolar  tissues  which  are  prone  to  suppurate  when  attacked 
by  infective  agents. 

Pelvic  cellulitis  usually  begins  as  a  lymphangitis,  following  the 
absorption  of  bacteria  from  some  pelvic  focus,  usually  the  Fallopian 
tubes.  A  salpingitis  is  the  most  frequent  cause  of  pelvic  abscess. 
The  arrangement  of  the  fascia  and  organs  is  such  that  the  inflam- 
matory exudates  gravitate  to  the  cul-de-sac  of  Douglas. 

Left  to  its  own  course,  the  abscess  may  open  into  the  vagina, 
rectum,  or  bladder;  less  frequently  through  the  abdominal  wall, 
saphenous  opening,  pelvic  floor,  obturator  foramen,  sacro-sciatic 
foramen,  or  into  the  peritoneal  cavity. 

Diagnosis. — -The  history  usually  given  points  to  an  attack  of  pelvic 
cellulitis,  following  an  abortion  or  complicated  confinement,  or  some 
pelvic  or  abdominal  traumatism.  The  temperature  remains  about 
100°  with  exacerbations  reaching  103°  to  104°.  There  are  all  the 
symptoms  of  septic  abortion. 

On  pelvic  examination  you  are  able  to  define  a  mass  bulging  down 
into  the  recto-uterine  pouch.     This  taken  with  the  fever  and  pain, 


412 


ABSCESS 


and  perhaps  some  edema  of  the  vulva,  points  without  doubt  to  the 
nature  of  the  trouble.  A  colpotomy  should  be  done  as  soon  as 
possible.  The  instruments  needed  are  a  speculum,  a  vulsellum 
forceps,  a  long  artery  forceps  or  dressing  forceps,  curved  scissors,  a 
scalpel,  an  irrigator,  drainage  tube,  and  iodoform  gauze.  General 
anesthesia  is  usually  necessary,  though  in  the  simpler  cases  local 
anesthesia  will  suffice.  Lithotomy  position;  the  thighs  held  well 
apart,  the  shoulders  lowered,  the  pelvis  slightly  elevated. 


Fig    317. — Incision  of  the  s-aginal  mucous  membrane  for  abscess  in  the  posterior 

cul-de-sac.     {Veau.) 


A  careful  antisepsis'.  Shave  the  vulva  and  disinfect  the  inner 
surface  of  the  thighs,  and  the  pubic  region  as  well.  Disinfect  the 
vagina,  rubbing  it  with  soap  and  water  first  and  being  careful  to 
reach  every  part  of  the  mucous  membrane,  using  the  finger  wrapped 
with  sterile  gauze.  Finally  irrigate  with  i  to  2000  bichloride  or 
other  antiseptic  solution.  Cover  the  outside  parts  with  sterile  towels. 
Now  retract  the  posterior  vaginal  wall  with  a  Sims'  speculum.  With 
the  vulsellum  forceps  seize  the  posterior  Hp  of  the  cervix  and  pull  the 
cervix  forward  (Fig.  317).     You  will  now  be  able  to  see  the  site  which 


PELVIC   ABSCESS 


4T.S 


is  lo  l)e  incised.  The  tumor  ma)'  be  conspicuous,  the  edema  and 
iluctuation  well  defined ;  or  nothing  but  some  edema  may  indicate 
the  presence  of  the  deeper  seated  inflammation.  Do  not  attempt 
a  mere  puncture,  however  well  defined  the  pus  cavity  may  be.  With 
a  curved  scissors  or  scalpel  incise  the  mucous  membrane  of  the  vault 
of  the  vagina  i  inch  behind  the  base  of  the  cervix.  ]\Iake  an  in- 
cision from  side  to  side,  but  do  not  approach  too  near  the  vaginal 
walls  else  the  arteries  there  may  be  wounded.  Enlarge  the  wound 
by  stripping  its  edges  back  a  little.  The  abscess  wall  is  exposed  and 
with  a  little  puncture  the  pus  will  flow.  ^  However,  it  may  be  that  the 


Fig.  318. — Showing  the  uterus  pulled 
down,  preparatory  to  opening  the 
abscess  in  the  posterior  cul-de-sac. 
(Veau.) 


Fig  3if>. — Showing  relations  of  abscess 
in  the  posterior  cul-de-sac.  Dotted  lines 
represent  drainage  tube.      (Veau.) 


pus  is  higher  up  and  separated  from  the  mucous  membrane  by  thick 
and  edematous  areolar  tissues,  and  this  must  not  be  taken  for  the 
abscess.  From  it  will  flow  a  serous  fluid  which  must  be  accepted  as 
a  proof  of  pus  higher  up. 

With  the  finger  or  an  artery  forceps  follow  the  posterior  wall  of 
the  uterus  upward.  Do  not  dissect  backward.  The  rectum  is  there 
(Fig.  318).  Follow  the  posterior  wall  of  the  uterus  to  avoid  danger. 
There  is  always  some  hemorrhage,  in  nowise  dangerous.  It  may  be 
necessary  to  dissect  upward  for  an  inch;  it  w^ill  seem  further  than  it 
really  is. 

When  once  the  cavity  is  opened  into,  enlarge  the  orifice  and  with 
the  finger  make  careful  search  for  a  secondary  cavity.  If  you  irri- 
gate, do  not  employ  much  pressure.     Do  not  pack  the  cavity  with 


414  .\BSCESS 

gauze.  Introduce  a  long  drainage-tube  to  the  top  of  the  cavity. 
Its  lower  end  must  not  protrude  at  the  vulva  (Fig.  319).  Pack  the 
vagina  lightly,  changing  the  packing  every  day  without  disturbing 
the  drainage-tube.  You  may  wash  out  the  vagina,  but  do  not  use 
much  force.  Replace  the  drainage-tube  by  a  smaller  one  about  the 
tenth  day  if  the  temperature  is  normal.  It  is  likely  that  it  will 
be  pushed  out  spontaneously,  and  if  it  cannot  be  reinstated  and  the 
temperature  is  normal,  it  is  certain  that  it  is  no  longer  necessary. 

SUBPHRENIC  ABSCESS 

A  localized  peritonitis  is  possible  only  in  those  localities  not 
occupied  by  coils  of  small  intestine.  The  region  immediately  below 
the  diaphragm  is  of  this  character,  and  it  is  practically  shut  off  from 
the  general  peritoneal  cavity  by  the  transverse  colon  and  its  meso- 
colon. This  space  is  subdivided  by  the  falciform  ligament  into  a 
right,  occupied  by  the  liver;  and  a  left  occupied  by  the  stomach, 
pancreas,  duodenum,  and  spleen.  Guibal  describes  five  sub- 
divisions of  the  subphrenic  space,  in  any  of  which  pus  may  collect 
(Revue  de  Chirurgie,  April,  1909). 

One  is  retro-peritoneal;  four  are  peritoneal.  The  retro-peritoneal 
space  contains  the  termination  of  the  esophagus,  the  posterior  border 
of  the  liver,  the  pancreas,  duodenum,  colon,  and  kidneys. 

Of  the  peritoneal  spaces  two  lie  between  the  liver  and  diaphragm 
and  may  be  the  seat  of  abscesses  following  lesions  of  the  liver,  gall- 
bladder and  ducts,  pylorus,  stomach,  and  duodenum.  The  third  or 
perisplenic  space,  may  be  infected  through  the  greater  curvature  of 
the  stomach,  the  spleen  or  splenic  flexure  of  the  colon.  The  fourth 
space,  or  the  posterior  gastro-hepatic,  may  be  infected  through  the 
posterior  surface  of  the  stomach,  the  pancreas,  or  liver. 

In  effect,  subphrenic  abscess  is  a  localized  purulent  peritonitis, 
and  whatever  part  the  various  adjacent  organs  may  play  in  its  pro- 
duction, yet  the  most  frequent  cause  of  subphrenic  suppuration  is 
appendicitis.  The  pus  forming  around  the  appendix,  or  behind  the 
cecum,  follows  the  ascending  and  then  the  transverse  colon  to  reach 
that  region. 

Sometimes  it  is  impossible  to  determine  the  original  focus  of  in- 


SUBPHRENIC   ABSCESS  415 

flammation.  Usually,  however,  if  the  history  of  the  case  is  suffi- 
ciently definite,  one  may  arrive  at  a  conclusion.  For  example,  if 
we  find  a  patient  with  subphrenic  abscess  and  there  has  been  a 
history  of  gastric  discomfort,  vomiting  of  blood,  etc.,  one  would 
decide  upon  perforating  gastric  or  duodenal  ulcer.  If  there  has  been 
a  history  of  jaundice  and  symptoms  pointing  to  the  right  hypochon- 
drium,  the  liver,  or  its  ducts,  should  be  accused;  if  there  has  been 
clear  history  of  previous  attacks  of  appendicitis  one  need  not  be  in 
doubt  as  to  the  starting-point  of  the  condition  with  which  he  has  to 
deal. 

Diagnosis. — You  will  have,  then,  usually,  a  history  of  some  visceral 
disturbance  followed  (very  quickly  in  case  of  perforation  of  the 
stomach)  by  a  chill,  fever,  malaise,  pain  in  the  upper  abdominal 
pole.  The  symptoms,  to  be  brief,  are  those  of  peritonitis  anywhere. 
Suspecting  from  these  symptoms  an  accumulation  of  pus  in  the  re- 
gion just  below  the  diaphragm,  proceed  to  a  methodical  examination 
by  means  of  inspection,  percussion,  and  palpation.  The  quantity 
of  pus  may  be  so  great,  or  so  near  the  front,  that  the  bulging  of  the 
anterior  abdominal  wall  may  settle  the  matter  without  further  ex- 
amination. In  obscurer  cases  it  will  be  necessary  to  recall  the  normal 
limits  of  dullness,  or  tympany  of  the  various  organs,  in  order  to  de- 
termine the  nature  and  degree  of  their  displacement.  Remember, 
too,  that  in  all  cases  following  perforation  the  abscess  cavity  will 
contain  gas  which  will  be  another  source  of  confusion.  But  after 
all,  in  the  typical  cases,  guided  by  the  history,  the  symptoms  of 
sepsis  and  the  local  signs,  one  can  rarely  go  astray.  Aseptic  aspiration 
may  be  resorted  to  in  the  doubtful  cases,  and  one  need  not  hesitate 
to  aspirate  several  times. 

But  previous  to  aspiration  the  patient  should  be  prepared  and 
should  be  operated  upon  immediately  if  pus  is  found.  The  X-ray 
may  be  helpful  in  diagnosis,  since  it  shows  an  abnormal  conformation 
of  the  diaphragm,  and  that  it  is  immobile  on  the  affected  side. 

The  great  majority  of  sufferers  from  this  condition  not  operated 
upon  die  from  sepsis.  A  general  peritonitis  may  supervene.  Left 
to  itself,  the  pus  may  open  into  the  alimentary  tract,  which  is  to  be 
regarded  as  a  compHcation  rather  than  a  cure,  for  such  cases  usually 
terminate  fatally  from  slowly  increasing  sepsis.     In  rare  instances 


4l6  ABSCESS 

it  may  ojjcn  through  the  abdominal  wall.  ]\Iost  often,  however,  it 
extends  toward  the  thorax,  opening  through  the  diaphragm  into  the 
lung  to  be  coughed  up.  Oftentimes  the  imminence  of  rupture  into 
a  bronchus  may  be  predicated  from  increased  pain  in  the  shoulder 
of  the  affected  side,  increased  cough  and  muco-purulent  or  sanguineous 
expectoration,  and  heightened  temperature.  The  pleurisy  nearly 
always  present  may  be  fibrous,  serous  or  purulent.  An  empyema, 
so  originating,  may  even  mask  the  primary  condition.  But  whether 
the  pus  opens  into  a  bronchus,  or  the  digestive  tube,  or  through  the 
abdominal  wall,  the  result  of  nature's  drainage  is  too  doubtful.  It  is 
imperative  to  operate  as  soon  as  a  diagnosis  is  made,  for  even  a  latent 
case  may  fire  up  suddenly  and  march  to  rapid  death.  The  prognosis, 
in  fact,  does  not  depend  more  upon  the  character  and  skillfulness  of 
the  operation  than  upon  its  timeUness. 

Operation.~Tht  method  of  operation  depends  upon  the  location 
of  the  pus;  it  may  be  (Aj  near  the  anterior  abdominal  wall,  or  (B) 
it  may  be  inaccessible  from  the  front. 

(A;  If  the  epigastric  region  is  bulging,  the  incision  should  be  over 
its  greatest  prominence  or  where  the  abscess  seems  to  point.  Red- 
ness and  edema  of  the  skin  should  be  taken  as  an  indication  that  the 
pus  is  well  walled  off  and  that  there  is  no  danger  of  the  incision  open- 
ing into  the  general  peritoneal  cavity,  which  is  an  accident  always  to 
be  guarded  against.  One  may  cut  directly  through  these  tissues 
whether  it  be  in  the  linea  alba  or  the  line  of  either  border  of  the 
rectus. 

Once  the  cavity  is  opened  and  emptied,  it  is  to  be  carefully  wiped 
out,  for  there  are  usually  collections  in  its  deeper  parts;  and  before 
drainage  is  inserted  it  should  be  cautiously  irrigated  with  normal 
salt  solution.  Moynihan  recommends  the  ''cigarette  drain" 
which  may  be  well  saturated  with  boracic  acid.  A  counter-opening 
in  the  loin  may  be  required  for  efiScient  drainage.  The  cavity  must 
fiU  in  by  granulation  which  may  require  six  or  eight  weeks. 

(B)  I.  If  the  abscess  is  behind  the  liver  on  the  right  side,  an  inci- 
sion along  the  costal  margin  is  perhaps  the  best.  Divide  the 
muscles,  or  even  resect  the  twelfth  rib,  and  then,  by  blunt  dissec- 
tion, follow  the  under  surface  of  the  diaphragm  until  the  abscess 
cavity  is  reached.     If  the  abscess  is  retro-peritoneal  it  may  be  nee- 


SUBPHRENIC   ABSCESS 


417 


essary  to  expose  the  upjier  pole  of  the  kidney  and  to  draw  it  down- 
ward and  forward,  exposing  the  renal  fossa  on  the  under  surface  of 
the  liver,  and  thence  work  upward  between  the  posterior  margin  of 
the  liver  and  the  diaphragm.  Insert  drainage-tubes  packed  about 
with  iodoform  gauze. 

2.  More  often  it  is  best  to  employ  the  transpleural  route  (Fig. 
320),  which  will  require  resection  of  a  rib  or  perhaps  more  than  one. 
The  incision  exposes  the  eighth  or  ninth  rib — right  side;  eighth  or 
seventh — left  side.  (For  technic  of  resection  of  rib,  see  page  506.) 
The  center  of  the  incision  lies  in  the  axillary  line  and  about  3H 
inches  of  rib  are  to  be  removed. 


Fig.  320. — Subphrenic  abscess.     Opening  in  the   mid-axillary  line.      {Bryant.) 


Now  determine  the  condition  of  the  pleura  of  which  the  cul-de-sac 
is  exposed.  In  this  region  the  pleura  is  easily  stripped  away  from 
the  chest  wall,  and  so  room  may  be  made  to  open  the  diaphragm 
without  opening  the  pleural  cavity.  If  this  can  be  done,  evacuate 
and  drain  the  abscess  as  described  above. 

Ordinarily  it  will  be  necessary  to  open  the  pleural  camty,  which  is 
first  to  be  aspirated  if  it  contains  serum;  or  opened  and  wiped  out 
if  it  contains  pus.  If  it  is  not  purulent  it  is  likely  to  become  so  un- 
less steps  are  taken  to  prevent  its  infection  by  suturing  the  diaphragm 
to  the  upper  lip  of  the  opening  in  the  chest  wall. 

You  are  now  ready  to  open  the  diaphragm  and  the  pus  cavity.  In 
some  cases  a  perforation  will  be  found  in  the  diaphragm,  and  this  is 
27 


4l8  ABSCESS 

to  be  merely  enlarged;  or,  if  inconvenient  for  drainage,  may  be  disre- 
garded and  the  incision  made  lower  down.     Drain. 

A  single  case  will  exemplify  some  of  the  characters  and  progress 
of  the  disease.  A  farmer,  thirty  years  of  age,  had  suffered  for  several 
years  with  a  severe  affection  of  the  stomach,  of  which  no  definite 
diagnosis  had  been  made.  Though  debilitated,  he  was  yet  able  to 
do  his  work  about  the  farm.  Without  warning  he  was  suddenly 
seized  with  a  violent  hematemesis. 

The  attack  continued  for  some  hours  without  relief  and  the  total 
amount  of  blood  vomited  was  appalling.  But  gradually  the  bleed- 
ing ceased,  leaving  the  patient  prostrate.  A  tardy  convalescence 
followed,  interrupted  by  an  intermittent  fever  diagnosed  as  malaria, 
a  month  elapsed  and  he  was  brought  to  bed  \\dth  a  fresh  access  of 
"ague" — chills,  fever,  and  exhausting  sweats.  At  this  time  a  con- 
sultation exposed  the  real  character  of  the  process.  There  was  a 
vast  accumulation  of  pus  in  the  left  side  involving  the  abdomen  and 
thorax.  A  constant  irritating  cough,  a  bloody  sputum,  severe  pain 
in  the  left  shoulder,  and  increased  fever  and  dyspnea  seemed  to 
indicate  the  nearness  of  rupture  into  a  bronchus.  In  fact  this  occurred 
wdthin  a  few  hours  after  our  examination.  A  large  amount  of  pus 
was  coughed  up  and  with  temporary  relief.  An  operation  was 
refused.  Indeed,  it  offered  but  little  hope  so  late  in  the  course  of 
the  disease.  A  week  later  he  died.  Had  the  perforation  of  the 
gastric  ulcer  been  recognized,  or  even  later  the  character  of  the  sepsis 
been  understood,  an  operation  would  have  saved  his  life. 

PSOAS  ABSCESS 

Psoas  abscess  is  a  term  sometimes  rather  loosely  applied  to  puru- 
lent collections  in  the  iliac  region.  Properly  speaking,  it  is  a 
tubercular  abscess  having  its  origin  in  caries  of  the  lower  cervical, 
dorsal,  or  lumbar  vertebrae. 

It  is  necessary  to  recall  the  arrangement  of  certain  muscles  and 
fascias.  The  psoas  muscle,  a  rounded  fleshy  mass,  lying  alongside 
the  bodies  of  the  lumbar  vertebrae,  extends  across  the  pelvic  brim, 
and  passes  in  front  of  the  hip-joint  to  be  inserted  into  the  lesser 
trochanter.     The  ihacus,  its  companion  muscle,  occupies  the  iliac 


PSOAS  ABSCESS  419 

fossa  and  converges  below  in  a  tendon  which  merges  with  that  of 
the  psoas.  These  muscles  are  covered  by  the  iliac  fascia  which  is  so 
attached  as  to  make  the  iliac  fossa  practically  a  closed  compartment. 

The  fascia  is  separated  from  the  muscles  by  a  loose  areolar  tissue 
in  which  suppuration  may  originate  the  which  constitutes  an  iliac 
abscess.  This  fascia  on  its  other  side  is  separated  from  the  perito- 
neum by  another  layer  of  connective  tissue — the  subperitoneal 
areolar  tissue,  which  is  liberally  supplied  with  fatty  tissue  and  con- 
stitutes a  site  of  lowered  resistance  to  germs  originating  in  the  pelvic 
viscera,  the  cecum,  the  sigmoid,  and  the  appendix.  Suppuration 
under  this  layer  usually  ends  as  a  pelvic  abscess. 

It  is  evident,  therefore,  that  an  iliac  abscess  beginning  as  such, 
and  abscess  in  the  subperitoneal  tissues,  are  quite  distinct  from  psoas 
abscess,  expect  that  all  have  common  points  of  possible  opening. 
The  iliac  fascia  covers  the  muscles  in  the  iliac  fossa,  but  it  also  ex- 
tends upward  in  such  manner  as  to  ensheath  the  psoas  and  sepa- 
rate it  from  the  bodies  of  the  vertebrae. 

In  the  case  of  caries,  the  products  of  decomposition  may  burst 
through  the  vertebral  ligaments  and  the  sheath,  and  thereafter  follow 
the  psoas  muscle  downward.  The  muscle  itself  may  be  decomposed 
in  whole  or  part,  and  the  accumulating  pus  may  be  directed  by  the 
tubular  sheath  to  its  point  of  termination  below  Poupart's  liga- 
ment to  the  outer  side  of  the  iliac  vessels.  Or,  again,  the  abscess 
may  burst  through  the  sheath  higher  up  and  point  in  the  loin 
(lumbar  abscess);  or  may  point  just  above  Poupart's  ligament  in 
the  gluteal  region,  the  pelvis,  the  scrotum,  or  thigh. 

The  diagnosis  of  psoas  abscess  rests  upon  the  history  of  the  case, 
which  points  to  spinal  trouble,  and  upon  the  presence  of  fluctuating 
swelling  in  the  iUac  fossa,  or  below  Poupart's  Ligament.  Usually 
the  hip  is  flexed  in  some  degree,  as  by  that  position  the  tension  in 
the  psoas  is  relieved. 

This  flexion  and  some  apparent  stiffness  in  the  joint  might  lead 
to  a  mistaken  diagnosis  of  hip-joint  disease.  The  swelling  is  to 
be  distinguished,  also,  from  a  hernial  tumor,  by  the  fact  that  it  is 
fluctuating  and  lies  at  the  outer  side  of  the  iliac  vessels. 

Treatment. — As  in  all  cases  of  tubercular  abscess,  secondary  in- 
fection and  amyloid  degeneration  are  most  to  be  dreaded.     For 


420  .\BSCESS 

that  reason,  spontaneous  rupture  and  treatment  by  small  incision 
and  prolonged  tubal  drainage  are  equally  dangerous. 

As  early  as  possible  an  aseptic  evacuation  must  be  practised. 
This  may  be  accomplished  by  puncture  and  the  subsequent  injec- 
tion of  iodoform  emulsion;  this  seems  the  advisable  procedure,  if 
the  abscess  is  pointing  in  the  region  of  Poupart's  ligament,  and  it  is 
likely  that  the  destructive  process  in  the  vertebra  is  an  abeyance. 
In  general,  most  authorities  recommend  the  operation  of  Treves, 
by  the  lumbar  route. 

Operation. — 'Begin  by  locating  the  last  rib,  the  crest  of  the  ilium, 
and  the  outer  border  of  the  erector  spinae.  The  incision,  2M  inches 
long,  with  its  center  half  way  between  these  bony  landmarks, 
follows  the  outer  border  of  the  erector  spinae  and  exposes  at  first 
the  lumbar  fascia. 

Divide  the  first  layer  of  the  lumbar  fascia  and  expose  the  erector 
spinae.  Develop  its  outer  border  the  whole  length  of  the  wound 
and  retract  the  muscle  inward,  exposing  the  middle  layer  of  the 
lumbar  fascia.  Divide  this  layer  which  exposes  the  quadratus 
lumborum. 

Divide  the  quadratus  lumborum  along  the  line  of  its  attachment 
to  the  tips  of  the  transverse  processes,  which  exposes  the  deep  or 
anterior  layer  of  the  lumbar  fascia.  Divide  this  layer  and  finally 
the  psoas  magnus  is  exposed.  Divide  the  attachment  of  the  psoas 
magnus  sufficiently  to  introduce  the  finger,  which  opens  up  the 
abscess  cavity  and  determines  the  condition  of  the  carious  vertebra. 

The  abscess  cavity  is  to  be  treated  by  thorough  irrigation  with 
an  antiseptic  solution,  wiped  vigorously,  or  even  curetted.  The 
various  la3'ers  are  sutured  without  drainage  and  an  antiseptic 
dressing  applied. 

Pfevious^to  suturing,  the  cavity  may  be  filled  with  iodoform  emul- 
sion; or,  as^^Walsham  suggests,  after  the  cavity  is  cleansed  it  may  be 
packed  with  strips  of  iodoform  gauze,  w^hich  are  to  be  changed  on  the 
third  or  fourth  day.  If  at  the  end  of  a  week  no  pus  has  appeared 
and  the  cavity  is  lined  with  healthy  granulations,  the  wound  may 
be  closed  by  secondary  suture. 


CHAPTER  XXI 
PHLEGMON :  ACUTE  SPREADING  INFECTIONS 

The  areolar  tissues  are  less  resistant  than  others.  The  strepto- 
cocci in  their  mode  of  development  tend  to  spread  out  so  that,  under 
favorable  circumstances,  the  streptococcic  infection  of  the  sub- 
cutaneous connective  tissues  becomes  one  of  the  most  dangerous 
conditions,  demanding  immediate  and  radical  surgical  intervention. 

The  rapid  development  of  toxins  makes  death  from  septicemia 
to  be  feared;  or,  short  of  this,  there  may  be  great  destruction  of 
tissue  and  subsequent  loss  of  function. 

Certain  regions,  owing  to  the  opportunities  for  infection  and  the 
arrangement  of  the  tissues,  are  more  likely  to  be  affected  than  others; 
but  the  general  symptoms  and  the  principles  of  treatment  are  the 
same. 

One  peculiarity  of  this  inflammation  is  that  pus  is  often  slow  to 
form,  so  that  when  the  engorged  tissues  are  incised  in  the  earlier 
stages,  merely  a  serum  exudes.  It  is  innocent-looking,  but  it  is 
toxic  in  the  extreme. 

The  point,  then,  is  this — do  not  wait  for  pus  formation  and 
fluctuation,  before  evacuating  these  products.  If  pus  has  formed, 
immediately  is  none  too  soon  to  operate. 

In  the  case  of  superficial  phlegmon  of  moderate  severity,  it  will 
often  be  harmless  to  try  to  localize  the  process  by  the  use  of  hot 
antiseptic  poultices  or  baths,  but  the  safest  thing  is  free  incision  for 
drainage. 

The  incision  must  reach  the  deepest  layer  of  the  affected  tiss.ues, 
as  anything  less  is  useless;  it  may  even  be  harmful  by  introducing  a 
new  infection  to  tissues  which  were  not  previously  involved. 

Slight  injuries,  with  subsequent  localized  accumulations  of  pus, 
are  often  the  source  of  an  infection  which  attacks  the  connective 
tissues,  reaching  them  by  way  of  the  lymphatics,  and  then  what  was 

421 


422 


phlegmon:  acute  spreading  infections 


a  mere  local  and  harmless  infection  at  first,  becomes  a  very  danger- 
ous diffuse  phlegmon. 

These  minor  conditions,  therefore,  are  emergencies  from  the  point 
of  view  of  prevention.  A  few  examples  will  serve  to  emphasize  the 
principles  governing  their  treatment. 

PANARIS 

This  is  an  infection  involving  the  tissues  about  the  finger-nail.  It 
may  be  limited  to  the  epidermis,  the  dermis,  the  subcutaneous  tissues, 
or  the  periosteum,  the  last  condition  being  usually  called  a  felon. 


Fig.  321. — Opening  a  purulent  phlyctena  or  "run  a  round."     {Veau.) 

Panaris,  Suhepidermic. — The  appearance  at  first  is  almost  that 
of  a  blister,  and  all  of  the  loosened  tegument  must  be  removed.  No 
analgesia  is  necessary,  as  the  epidermis  is  non-sensitive. 

Begin  by  pricking  the  phlyctena  with  the  point  of  the  bistoury,  and 
then  trim  around  its  whole  circumference  with  pointed  scissors 
(Fig.  321). 

Carefully  observe  the  denuded  surface,  and  a  small  opening  may 
be  found,  leading  to  a  deeper  cavity  (button-hole  abscess)  which  will 
require  incision. 

Complete  the  treatment  by  a  prolonged  antiseptic  bath  and 
antiseptic  dressing. 


PHLEGMON   OF   THE   FINGER  423 

Panaris,  Subungual. — In  this  form  the  pus  accumulates  under  the 
nail  and  loosens  it.  It  will  be  necessary  to  remove  the  part  of  the 
nail  lying  over  the  pus  accumulation.  A  cure  can  be  obtained  only 
at  that  price. 

If  it  is  confined  to  one  side  only,  the  skin  is  removed  as  described 
above,  the  sharp  point  of  the  scissors  introduced  under  the  nail, 
and  enough  of  it  resected  to  expose  the  suppurating  surface.  If  both 
sides  are  involved,  remove  the  nail  completely. 

Panaris,  Subcutaneous  (Felon). — Incise  as  soon  as  pus  is  suspected. 
No  harm  can  be  done  even  if  there  is  no  pus,  while  a  day's  delay 
after  pus  has  formed  may  make  a  great  difference. 


Fig.  322. — Illustrating  the  situation  of  the  pus  in  a  felon;  the  dotted  lines  represent  the 

hmits  of  the  incision.     (Veau.) 

Under  local  anesthesia  (Figs.  8,  9),  make  a  longitudinal  incision 
in  the  middle  of  the  palmar  surface  where  the  pain  is  greatest 
(Fig.  322). 

Do  not  make  a  mere  puncture,  as  the  whole  pus  cavity  must  be 
exposed.  Incise  deliberately  and  let  the  first  stroke  cut  long  and 
deep  enough,  after  which  explore  the  cavity  with  a  small  probe. 

If  there  is  a  palmar  prolongation,  enlarge  the  opening,  and  if 
there  is  a  dorsal  prolongation,  which  is  quite  rare,  make  a  counter- 
incision  on  the  dorsum  of  the  finger. 

Immerse  the  hand  in  an  antiseptic  or  normal  salt  solution  for  an 
hour.  A  drainage-tube  is  unnecessary,  if  the  incision  is  properly 
made. 

Dress  with  moist  antiseptic  gauze  and  give  the  hand  a  hot  bath 
with  each  daily  renewal  of  the  dressing. 

After  two  to  eight  days,  or  when  suppuration  has  ceased,  employ 
a  dry  dressing.  The  dry  dressing  favors  cicatrization,  but  the 
moist  dressing  best  relieves  pain. 


424 


phlegmon:  acute  spreading  infections 


SUPPURATIVE  INFLAMMATION  OF  TENDON  SHEATHS 

Every  neglected  infection  of  the  fingers  or  palm  may  become  a 
phlegmon  of  the  tendon  sheaths. 

The  great  danger  of  these  phlegmons  is  destruction  or  adhesion 
of  the  tendons,  so  that  the  finger  remains  permanently  flexed  or 

extended,  unsightly,  and  more  or 
less  useless. 

A  threatened  suppuration  may 
often  be  prevented  by  a  prolonged 
immersion  in  hot  antiseptic  or 
normal  salt  solution.  This  should 
be  continued  for  an  hour  and  used 
twice  daily. 

The  Bier  treatment  is  excellent 
for  this  purpose.  This  treatment 
is  to  be  applied  after  suppuration 
occurs,  but  not  until  the  pus  is 
evacuated.  It  shortens  the  in- 
cision required  and  the  time  of 
repair. 

As  soon  as  pus  is  suspected,  in- 
cise freely.  Recall  the  anatomy  of 
the  parts  (Fig.  323).  The  sheaths 
of  the  flexor  tendons  extend  into 
the  palm,  whence  the  necessity  of 
a  palmar  incision.  The  tendon 
sheaths  of  the  thumb  and  of  the 
little  finger  communicate  with  the 
common  tendon  sheaths  in  the 
palm,  whence  the  additional  grav- 
ity w^hen  they  are  involved.  The 
common  sheaths  extend  from  the 
palm  under  the  annular  ligament  above  to  the  wrist-joint,  whence  the 
necessity  of  incision  in  the  forearm.  There  is  in  this  incision  an 
element  of  danger  by  reason  of  the  median  nerve,  which  lies  on  the 
middle  of  the  front  of  the  wrist  between  the  two  common  sheaths. 


Fig.  323. — Diagram  illustrating  the 
arrangement  of  the  synovial  sheaths  in  the 
hand.  Note  that  the  sheath  of  the  tendon 
of  the  little  finger  communicates  with  the 
sheath  common  to  all  the  flexors  of  the 
fingers  in  the  wrist  and  palm.  Note  also 
that  the  sheath  of  the  flexors  of  the  thumb 
extends  into  the  wrist  beyond  the  annular 
ligament.  The  median  nerve  passes  under 
the  annular  ligament  between  these  two 
common  sheaths.     (Veau.) 


PHLEGMUN  OV   TENDON  SHEATHS 


The 


The  uhiar  artery  lies  on  the  common  sheath  on  the  uhiar  side, 
incision  must  pass  between  the  artery  and  the  nerve. 

Phlegmons  of  the  sheaths  of  the  first,  second,  and  third  fingers  are 
not  likely  to  extend  further  than  the  middle  of  the  palm,  while,  on 
the  contrary,  phlegmons  of  the  sheaths  of  the  thumb  and  little  finger 
are  likely  to  point  above  the  wrist. 


Fig.  324. — Suppuration  of  digital  syno- 
vial sheath.     Incisions.      (Veau.) 


Fig.  325. — Opening  into  the  upper  part  of 
the  ulnar  synovial  sheath.      (Veau.) 


Operation  for  Phlegmon  of  the  Synovial  Sheaths  of  the  Flexor  Tendons 
in  the  Fingers. — A  general  anesthesia  is  usually  necessary,  for  the 
pain  is  great.  Make  an  incision  about  an  inch  long  in  the  middle  of 
the  palmar  surface  over  the  point  of  great  swelling.  Incise  to  the 
bone  to  be  sure  of  opening  the  tendon  sheath.  The  wound  must  be 
of  uniform  length  in  the  superficial  and  deeper  tissues  (Fig.  324). 
If  necessary,  make  a  similar  incision  over  each  of  the  phalanges  and 
in  the  palm,  but  avoid  opening  into  the  joints.  If  the  sheath  is 
distended  with  pus,  a  drainage-tube  is  easily  passed  through  from 
one  incision  to  the  other. 


426 


phlegmon:  acute  spreading  infections 


When  the  pus  has  been  located,  immerse  the  hand  in  a  hot  normal 
salt  solution  for  an  hour  and  repeat  twice  daily.     This  greatly  favors 
the  evacuation  of  pus  and  subsequent  repair. 
Employ  moist  antiseptic  dressings  at  first. 

Operation  for  Phlegmon  of  the  Ulnar  Synovial  Sheath. — ^Continuous 
with  the  synovial  sheath  of  the  flexor  tendon  of  the  little  finger,  the 

ulnar  synovial  sheath  is  larger  than 
the  radial  and  its  suppuration  more 
serious. 

These  phlegmons  are  usually  con- 
secutive to  neglected  infections  of 
the  little  finger. 

Complete  drainage  is  indispensa- 
ble. Begin  by  making  an  incision 
over  the  radial  border  of  the  mini- 
mal metacarpal  (Fig.  325).  Avoid 
wounding  the  palmar  arch,  which 
might  require  hgation;  but,  after  all, 
this  is  not  a  serious  accident  and 
permits  a  freer  incision. 

When  the  pus  is  reached,  enlarge 
the  incision  so  that  the  tendon  may 
be  seen  the  entire  length  of  the  wound. 
Superficially  and  deep,  the  incision  must  be  of  the  same  length. 

Next  introduce  a  grooved  director  into  this  incision  and  push  it 
through  the  synovial  cavity  until  its  point,  passing  under  the 
annular  ligament,  can  be  felt  beneath  the  skin  of  the  wrist.  Incise 
carefully  over  this  point  until  it  is  exposed,  keeping  to  the  inside  of 
the  tendon  of  the  palmaris  longus  to  avoid  the  median  nerve.  When 
the  point  of  the  grooved  director  is  fully  exposed,  enlarge  the  incision 
to  an  inch  and  a  half. 

No  artery  of  importance  will  be  wounded.  Pass  a  drainage-tube 
through  from  one  incision  to  the  other  (Fig.  326). 

Operation  for  Phlegmon  of  the  Synovial  Sheath  on  the  Radial  Side. — • 
The  palmar  incision  may  be  made  through  the  muscles  of  the  thumb 
along  the  line  of  the  metacarpal,  but  it  is  preferable  to  make  it  in 
the  commissure  between  the  thumb  and  index  finger. 


Fig.  326. — Drainage   of    phlegmon   of 
the  ulnar  synovial  sheath.     {Veau.) 


PHLEGMON    OF    FOREARM 


427 


Make  an  incision  two  lingers'  breadth  in  length.  At  the  depth 
of  I  or  2  inches  you  will  find  the  pus.  Pass  a  grooved  director 
along  the  sheath  as  in  the  preceding  case.  It  emerges  beneath  the 
skin  above  the  annular  ligament.  Locate  and  expose  the  point  of 
the  director;  in  incising  keep  to  the  outside  to  avoid  the  median 
nerve.  The  radial  artery  is  in  no  danger,  as  it  is  too  far  to  the 
outside  (Fig.  327). 


Fig.  327. — Drainage  of  the  radial  synovial 
sheath.     (Veau.) 


Fig.  328. — Drainage  completed. 


In  the  same  manner  as  before,  pass  a  drainage-tube.  Immerse 
the  hand  twice  daily  for  an  hour  in  hot  normal  salt  solution,  and 
employ  a  moist  antiseptic  dressing.  The  drainage-tube  will  probably 
be  unnecessary  after  the  eighth  or  tenth  day  (Fig.  328). 

SUBAPONEUROTIC  PHLEGMON  OF  THE  FOREARM 

By  direct  infection,  or  by  extension  of  infection  from  the  hand, 
the  areolar  tissues  beneath  the  fascia  of  the  forearm  may  become 
the  site  of  a  diffuse  suppurative  inflammation. 


428 


phlegmon:  acute  spreading  infections 


If  neglected,  it  follows  the  connective  tissues  into  the  intermuscular 
spaces  and  finally  all  the  soft  parts  are  more  or  less  involved.  Free 
incision  must  be  resorted  to  without  delay.  In  the  earlier  stages  no 
pus  will  be  present,  but  a  straw-colored  serum  pours  out  along  the 
line  of  incision. 

Operation. — General  Anesthesia.  Over  the  site  of  the  greatest 
swelling,  make  a  free  incision  in  the  long  axis  of  the  member.     This 


Fig.  329. — Incising  the  forearm  for  deep 
phlegmon.  The  grooved  director  search- 
ing for  posterior  prolongations  of  the  pus 
formation.      {Veau.) 


Fig.  330. — Note  manner  of  fixing  tubes 
in  drainage  for  phlegmon  of  the  forearm. 
{Veau.) 


incision  will  traverse  a  thick,  infiltrated  layer  to  reach  the  aponeurosis, 
which  incise  carefully,  when,  in  most  cases,  the  pus  will  pour  out. 
Enlarge  the  opening  sufficiently  on  the  grooved  director. 

Irrigate  thoroughly  with  hot  normal  salt  solution  and  mop  out  with 
sterile  gauze.  With  a  grooved  director  explore  all  the  parts  of  the 
cavity  for  a  diverticulum  (Fig.  329). 


PHLEGMON   OF  THE  NECK  429 

If  necessary  make  a  counter-opening.  Tie  such  of  the  larger 
vessels  as  are  divided  and  place  several  large  drains  (Fig.  330). 
Change  the  dressing  twice  daily,  irrigating  each  time  with  hot  normal 
salt  solution. 

About  the  eighth  day,  smaller  drains  may  replace  those  first  em- 
ployed and  these  are  usually  unnecessary  after  two  weeks.  Watch 
the  temperature  closely.  It  is  rises,  there  is  a  retention  of  pus,  the 
site  is  not  sufficiently  drained,  or  there  is  a  new  infection. 

DIFFUSE  PHI.EGMON  OF  THE  ARM 

All  the  soft  parts  are  involved  and  infiltrated  with  serum.  The 
arm  is  greatly  swollen,  edematous,  and  there  are  marked  symptoms 
of  septicemia. 

General  anesthesia  is  indispensable.  The  freest  kind  of  incision, 
even  down  to  the  bone  from  above  downward,  is  essential.  Three  or 
four  such  openings  are  not  too  many. 

Irrigate  freely  with  hot  normal  salt  or  bichloride  solution.  Moist 
antiseptic  dressings  should  be  used  and  at  first  should  be  changed 
several  times  daily. 

Incision  with  the  Thermo-cautery,  Lejars. — -With  the  thermo-caiitery 
make  several  large  incisions  in  the  axis  of  the  member,  each  at  least 
four  fingers'  breadth  in  length  and  about  two  fingers'  breadth  apart 
(Fig.  331).  Under  the  skin  will  be  found  a  thick  layer,  infiltrated 
with  bloody  serum.  Cutting  through  this,  the  aponeurosis  appears, 
which  incise  and  thus  expose  the  muscles. 

On  the  inner  side  avoid  the  vessels.  If  some  of  the  large  sub- 
cutaneous vessels  are  opened  and  bleed  too  freely,  tie  them.  Irrigate 
and  dress  with  sterile  gauze  saturated  with  peroxide  of  half  strength 

Change  the  dressing  and  irrigate  two  or  three  times  daily. 
Change  to  dry  dressings  when  granulation  is  well  under  way.  Later, 
skin  grafting  may  be  necessary.  In  the  long  time  necessary  for 
repair,  massage  and  passive  motion  must  be  given  the  muscles. 

PHLEGMON  OF  THE  NECK 

An  infection  in  the  floor  of  the  mouth  may  become  diffuse  and 
spread  rapidly   down  the   neck.     The  symptoms  of  sepsis  will  be 


4.^o 


phlegmon:  acute  spreading  infections 


aggravated  in  the  extreme  and  death  may  rapidly  supervene,  either 
from  sepsis  or  asphyxia.  The  whole  neck  may  be  brawny  and 
edematous,  and  the  patient's  condition  is  pitiable  indeed. 

Lejars  recommends  the  thermo-cautery  as  offering  the  best  hope 
of  a  cure,  though  seemingly  brutal. 


Fig.  331- — Incising  a  phlegmon  of  the  arm  with  the  cautery.     {Veau.) 

Under  general  anesthesia  several  deep  vertical  incisions  are  made 
with  the  thermo-cautery  with  numerous  punctures  between  (Fig. 
S32).  Do  not  go  too  deep  over  the  anterior  border  of  the  sterno- 
mastoid,  for  the  great  vessels  are  there. 

Pack  each  incision  and  puncture  with  gauze  saturated  with 
peroxide  of  hydrogen,  and  cover  the  whole  with  a  similar  dressing 


PHLEGMON    OF   THE    NECK 


431 


and  absorbent  cotton.     'J'hc  dressing  must  be  kept  saturated  with 
the  peroxide.     In  the  meantime  use  the  antistreptococcic  serum. 

Watson  Cheyne  also  urges  the  use  of  the  serum,  but  does  not  use 
the  thermo-cautery.     His  plan  is  to  incise  through  the  deep  fascia 


Fig.  332. — Manner  of  incising  phlegmon  of  neck  with  the  cautery.     (Veau.) 

in  several  places,  enlarging  the  openings  by  blunt  dissection.  The 
wounds  are  to  be  freely  sponged  with  undiluted  carbolic  acid, 
powdered  with  iodoform,  and  packed  with  strips  of  iodoform  gauze. 


CHAPTER  XIX 
ACUTE  OSTEOMYELITIS 

This  is  an  acute  infection  of  great  gravity,  more  often  due  to  the 
staphylococcus  or  the  streptococcus;  but,  in  rare  instances,  the  pneu- 
mococcus,  bacillus  coli  communis,  or  tubercle  bacillus  may  be  the  ex- 
citing cause. 

Usually  the  germ  reaches  the  affected  site  by  way  of  the  blood 
current,  originating  in  a  focus  quite  unsuspected.  In  every  case  of 
bone  infection  especially  where  first  one  bone  and  then  another 
is    involved,    the    middle    ear    conditions    must    be    investigated. 

In  many  of  these  cases  a  quiescent  mastoid  abscess  is  the  focus  con- 
stantly supplying  the  blood  stream  with  new  crops  of  the  infective 
agent.  The  patient  recovers  completely  only  after  the  mastoid  is 
drained.  In  other  cases  the  germ  reaches  the  affected  site  by  way  of 
the  lymph  channels  or  by  continuity  of  tissue,  the  primar}^  focus 
not  having  revealed  itself.  But  in  all  cases  the  predisposing  causes 
are  found  in  certain  constitutional  states  and  sHght  traumatisms. 

The  diagnosis  is  not  always  easy  in  the  beginning,  as  the  constitu- 
tional symptoms  may  be  marked  before  the  local  signs  are  quite 
definite. 

Acute  infectious  arthritis,  the  so-called  inflammatory  '' rheuma- 
tism," is  the  wrong  diagnosis  most  often  made  but  this  affection 
does  not  have  the  symptoms  of  sepsis,  though,  indeed,  the  fever 
may  be  high.  The  pain  is  usually  in  the  joint  and  usually  in  more 
than  one  joint. 

Subacute  arthritis  likewise  involves  the  joint,  although  it  is  to  be 
remembered  that  an  arthritis  may  be  secondary  to  osteomyelitis 
and  overshadow  it  clinically,  but  the  history  of  the  case  will  usually 
decide  between  arthritis  and  osteomyelitis. 

Erysipelas  may  be  thought  of  when,  after  a  little  while,  the  skin 
becomes  brawny  and  edematous,  but  in  erysipelas  the  skin  is  so  in- 
volved from  the  first. 

432 


ACUTE    OSTEOMYELITIS  4;^3 

The  symptoms  may  seem  to  sug<^osl  typhoid  fever  or  oilier  infec- 
tious fevers,  but  these  may  usually  be  ruled  out  by  the  absence  of 
characteristic  features. 

The  symptoms  of  meningitis  are  often  present,  but  by  the  time  they 
arise,  the  local  conditions  point  to  the  nature  of  the  trouble. 

The  general  symptoms  are  those  of  sepsis;  high  fever  beginning 
with  a  chill,  rapid  pulse,  foul  tongue,  and  in  the  severe  cases,  pro- 
found prostration,  and  finally  delirium. 

Locally  the  pain  over  the  affected  area  is  often  extreme,  and  the 
least  pressure  tends  to  aggravate  it.  Gradually,  as  the  inflamma- 
tion spreads  from  the  marrow  through  the  bone  to  the  periosteum, 
the  skin  begins  to  swell,  redden,  become  edematous,  and  finally 
shows  fluctuation. 

In  the  virulent  cases  not  operated  upon,  the  patient  dies  within 
the  first  few  days  from  septic  infection.  In  the  milder  cases,  even, 
large  areas  of  the  bone  necrose. 

The  treatment,  then,  must  be  prompt.  It  is  an  emergency. 
There  is  only  one  thing  of  any  use  to  be  done.  The  suppurating 
marrow  must  be  evacuated  and  the  medullary  canal  freely  opened 
and  cleaned  out.  Local  applications,  poultices,  or  even  incisions 
through  the  periosteum  are  illusory.  The  bone  must  be  trephined, 
its  cavity  opened  up  at  its  most  accessible  part,  and  all  the  inflamed 
tissue  scraped  aw^ay.  The  whole  extent  of  the  canal  may  need  to  be 
opened,  irrigated,  drained,  and  treated  with  vigorous  antisepsis. 
Free  incision  over  the  affected  area,  choosing  the  easiest  and  least 
dangerous  approach,  if  possible  reaching  the  bone  through  inter- 
muscular septa;  incision  and  stripping  of  the  periosteum  over  the 
proposed  site  of  trephining;  opening  the  bone  cavity  freely,  wiping 
out  the  pus,  curetting  and  chiseling  aw^ay  the  necrotic  bone,  sw^abbing 
out  the  cavity  with  pure  carbohc  acid  followed  by  alcohol;  obliter- 
ating the  larger  cavities  partially  with  muscle  or  fat  when  possible 
and  employing  tubal  drainage — -these  are  the  principles  of  treatment, 
and  aided  in  this  way  nature  usually  effects  a  cure. 

In  the  case  of  long  standing  where  the  cavity  is  surrounded  by  new 
bone  sclerosed  and  lacking  in  osteoblasts  it  may  be  necessary  to  use 
an  artificial  filling. 

28 


434 


ACUTE    OSTEOMYELITIS 


Mosetig-Moorhof's^  iodoform-plombe  is  applicable  to  such  cases 
as  these.     It  is  prepared  as  follows: 

Fqual  parts  of  spermaceti  and  sesamoil  are  melted  in  an  evaporat- 
ing dish,  then  filtered  into  a  Florentine  flask  and  sterilized  in  a  water- 
bath;  40  grams  of  finely  powdered 
iodoform  (not  crystallized)  are  put 
into  a  sterile  flask,  and  60  grams  of 
the  hot  fat  mixture  are  added,  under 
constant  agitation.  This  agitation 
must  be  continued  without  interrup- 
tion, until  the  mass  solidifies.  The 
flask  is  closed  with  a  sterile  rubber 
stopper.  Before  using,  the  plombe 
is  to  be  heated  in  water-bath  to  a 
Httle  above  50°  C. 

The  bone  cavity  is  most  carefully 
prepared  for  the  reception  of  the 
filling.  Everything  must  be  re- 
moved down  to  sound  bone.  The 
laws  of  gravity  must,  of  course,  be 
observed  in  filling  the  cavity.  If  the 
cavity  is  large,  it  is  advisable  to  fill  it 
in  several  steps,  letting  the  plombe 
solidify  in  one  portion,  before  any  is 
poured  into  another.  The  cavity 
must  be  dry  before  the  mixture  is 
pourea  in.  This  may  be  accomplished 
by  sponging,  by  the  application  of 
adrenalin  to  oozing  points,  by  hot  air, 
etc.  The  course  of  healing  after  iodo- 
form filling  is  aseptic  as  a  rule.  Some- 
times the  temperature  rises  within 
the  first  two  or  three  days — -so-called  aseptic  fever — which  yields 
to  a  cathartic.  The  disposition  of  the  sprouting  granulations  toward 
the  solidified  plombe  varies  between  complete  closure  of  the  wound 
and  healing  by  primary  intention,  and  incomplete  closure.     In  the 

^  Surgery,  Gynecology  and  Obstetrics,  Vol.  3,  No.  4. 


I 


Fig.  333. — Exposing  the  tibial  crest, 
opening  into  the  subperiosteal  abscess. 
iVeau.) 


OSTEOMYELITIS    OF   THE    TIBIA 


435 


first  cases,  absorption  of  the  plombe  is  effected  through  the  steadily 
advancing  granulations  by  vital  phenomena;  in  the  second,  by  par- 
tial displacement  and  expansion. 


OSTEOMYELITIS   OF   THE   UPPER   END    OF   THE  TIBIA 

Here  the  disease  occurs  more  frequently  and  here,  fortunately,  is 
most  easily  operated  upon. 

General  anesthesia;  special  isntruments:  a  mallet,  a  gouge,  a 
periosteal  elevator  or  rugine,  and  curette. 


Fig.  334. — Trephining  of  the  tibia; 
making  the  orifice.    iVeau.) 


Fig.  335. — Enlarging  the  orifice  and  ex- 
posing the  medullary  canal.     {Veau.) 


Begin  by  elevating  the  limb  to  empty  the  blood  vessels.  About 
the  middle  of  the  thigh  apply  an  Esmarch  tube.  Do  not  apply  an 
Esmarch  bandage,  beginning  at  the  toe  and  extending  upward,  for 
that  only  spreads  infection. 

On  the  right  side,  the  incision  commences  at  the  level  of  the  tuber- 
osity and  extends  to  the  middle  of  the  leg,  foUo^dng  the  sharp  crest 
of  the  tibia  just  to  its  inner  side.  However  engorged  the  tissues  may 
be,  this  first  incision  reaches  to  the  bone  (Fig.  333). 

Often  by  this  first  stroke,  one  opens  into  a  pus  cavity.     Do  not  be 


436 


ACUTE    OSTEOMYELITIS 


beguiled  by  this  into  thinking  the  operation  completed.  This  collec- 
tion is  to  be  evacuated  and  drained,  of  course,  but  there  is  another 
one  in  the  central  canal.  Extend  the  incision  to  the  limit  of  the 
loosened  periosteum.     AMth  the  rugine,  expose  the  anterior  surface 

of  the  bone.  A  fistulous  opening 
leading  to  the  medullary  canal  may 
possibly  be  found.  In  any  event, 
proceed  to  trephine. 

At  the  upper  end  of  the  incision 
make  an  opening  with  the  gouge 
down  to  the  canal.  The  pus  will  be 
almost  certain  to  flow,  but  it  is  often 
difficult  to  distinguish  from  the 
marrow. 

At  the  lower  end  of  the  incision, 
make  another  opening  (Fig.  334). 
If  again  pus  appears,  it  is  certain  that 
the  lowest  limit  of  the  suppuration 
has  not  been  reached  and  you  must 
lengthen  the  incision.  Continue  to 
expose  the  canal  until  the  full  extent 
of  inflammation  has  been  exposed. 
It  may  require  the  removal  of  the 
whole  anterior  surface  of  the  tibia, 
but  you  are  engaged  in  saving  life,  so 
that  bone  is  a  minor  consideration. 
Chisel  away,  then,  all  the  anterior 
Fig.  336.— Trephining  of  the  tibia  com-    ^yafl  between  the  two  hmits  of  sup- 

pleted.     Tubes  in  place.     (Veau.)  ,  ,_.  v         ^ 

puration  (Fig.  335).  Curette  vigor- 
ously the  medullary  canal  down  to  firm  and  uninflamed  bone, 
and  especially  curette  the  upper  part,  for  there  the  suppuration  is 
greatest. 

In  the  case  of  a  child,  the  epiphyseal  cartilage  is  quickly  reached, 
and  this  one  should  try  to  avoid,  since  too  free  removal  will  end 
linear  growth. 

Mop  the  ca\'it3'  with  sterile  gauze,  swab  with  carbolic  acid  followed 
by  alcohol  or  Tr.  of  iodine.     If  considerable  oozing  persists  it  may 


OSTEOMYELITIS    OF   THE    HUMERUS 


437 


be  necessary  to  pack  with  iodoform  on  sterile  gauze,  otherwise  simple 
tubal  drainage  is  sufficient. 

The  drainage,  however,  must  include  the  subperiosteal  areas  as 
well  as  the  medullary  canal  in  the  septic  cases  (Fig.  336). 

If  the  operation  has  been  delayed,  the  muscles  of  the  calf  may 
be  infiltrated  with  pus  and  will  recjuire  drainage  as  in  diffuse  phlegmon. 

If  there  is  serous  effusion  into 
the  joint,  it  will  require  no 
especial  treatment,  for  it  will 
gradually  be  absorbed  as  the 
osteomyelitis  is  cured. 

If  the  joint  is  suppurating,  it 
is  quite  different  and  another 
operation  is  required  (see  oper- 
ation for  Purulent  Arthritis). 

Over  the  trephined  area,  ap- 
ply a  moist  dressing  and  change 
daily.  As  the  exudate  becomes 
less  abundant,  change  to  a  dry 
dressing  and  change  the  pack- 
ing in  the  canal  every  other 
day.      Smaller  drains   may  be 

inserted  about  the  tenth  day,  and  are  removed  entirely  when  the 
suppuration  shall  have  ceased. 

As  Veau  says,  this  intervention  is  only  the  first  act  of  a  prolonged 
and  tedious  process  and  this  the  family  should  understand  before- 
hand. After  several  months,  it  may  be  necessary  to  remove  some 
necrosed  bone;  and,  long  after  the  cure  appears  complete,  the  trouble 
may  recur. 

OSTEOMYELITIS   OF  THE   UPPER   END   OF   THE 

HUMERUS 

Begin  the  incision  a  finger's  breadth  below  the  clavicle,  following 
the  axis  of  the  humerus.  Prolong  it  downward  5  or  6  inches. 
The  incision  will  traverse  the  deltoid  near  its  anterior  border.  Sepa- 
rating the  hps  of  the  wound,  divide  the  periosteum  and  proceed  to 
trephine  and  drain  as  in  the  preceding  case  (Fig.  337). 


Fig.   337. — Osteomyelitis  of  the  humerus. 
iMarsee.) 


438  ACUTE    OSTEOMYELITIS 

OSTEOMYELITIS   OE  THE  LOWER   END   OF   THE 

HUMERUS 

Make  an  incision  8  to  15  inches  in  length  in  the  Hne  of,  and 
ending  below  at,  the  external  condyle.  The  incision  wiU  traverse 
the  thick  fibers  of  the  triceps.     Trephine  and  drain.     If  it  is  neces- 


FiG.  338. — Cross  section  showing  manner  of  placing  drains  after  trephining  the 

femur.     (Veau.) 


sary  to  make  an  internal  counter-opening  for  a  drain,  remember 
the  situation  of  the  ulnar  nerve.  If  the  whole  bone  is  affected,  the 
same  principles  are  involved.     The  prognosis  is  exceedingly  grave. 


USlEOMYELiUS    Of    itMUR  439 

OSTEOMYELITIS  OF  THE  LOWER   END   OF   THE 

FEMUR 

Make  the  incision  along  Ihe  antero-internal  border  of  the  thigh, 
traversing  the  fleshy  vastus  internus. 

The  femoral  vessels  are  behind  this  line.  The  bone  is  deeply 
placed  and  the  operation  difficult,  but  trephine  thoroughly.  Drain 
the  medullary  cavity  and  the  periosteal  abscess  (Fig.  338). 

OSTEOMYELITIS  OF  THE  UPPER  EXTREMITY  OF  THE 

FEMUR 

Make  the  incision  along  the  outer  surface  of  the  thigh  over  the 
great  trochanter.  Divide  the  aponeurosis  of  the  gluteal  muscle, 
trephine,  and  drain. 


CHAPTER  XX 
SEPTIC  ARTHRITIS 

Septic  arthritis  is  acute  purulent  inflammation  of  the  joints,  due 
to  the  presence  of  an  infective  agent,  more  frequently  the  staphylo- 
coccus or  the  streptococcus.  The  infection  may  reach  the  joint 
through  a  wound,  by  way  of  the  blood  vessels  or  through  the  lymph 
channels. 

This  purulent  inflammation,  therefore  either  follows  direct  injury, 
or  is  a  sequel  to  various  infective  diseases,  such  as  typhoid  fever,  gon- 
orrhea, scarlet  fever,  or  osteomyelitis;  but  by  no  means  are  all  the 
joint  inflammations  following  these  conditions  purulent. 

Purulent  inflammations  are  to  be  distinguished  from  non-septic 
inflammation  both  by  the  symptoms  and  the  physical  signs.  The 
symptoms  are  those  belonging  to  sepsis,  for  here  it  exists  in  a  high 
degree.  The  tongue  is  brown  and  the  temperature  is  very  high,  the 
pulse  is  weak  and  rapid,  there  are  the  appearances  of  prostration  and 
finally  delirium  ensues.  The  pain  is  extreme  and  aggravated  by  the 
least  touch.  With  respect  to  the  physical  signs,  there  is  marked 
swelling  of  the  joint  and  the  skin  is  red  and  edematous,  not  only 
over,  but  above  and  below  the  joint,  and  fluctuation  is  usually  to 
be  detected. 

Treatment. — This  is  an  emergency  of  the  first  rank.  It  is  an  inter- 
vention designed  to  save  the  function  of  the  joint;  and  sometimes 
even  life  is  threatened. 

There  is  but  one  indication,  once  the  diagnosis  is  made,  viz. :  to 
open  the  joint  by  free  incision  and  counter-incision,  that  every  part 
of  it  may  be  reached  and  drained. 

The  most  careful  antisepsis  is  to  be  observed.  The  limb  is  to  be 
as  carefully  cleansed  as  if  no  pus  was  expected. 

Scrub  the  skin  over  the  joint  (the  knee,  for  example),  the  upper 
third  of  the  leg,  and  lower  third  of  the  thigh  with  soap  and  water  and 
with  ether  and  bichloride.     Sterilized  instruments  are  to  be  used; 

440 


ARTIIROTOMY    OF    THE    KNEE 


441 


I  hey  are  simple,  a  scalpel,  a  few  artery  forceps,  some  rubber  drains, 
and  an  irrigator.  The  whole  aim  is  to  secure  ample  drainage  and 
su])sequent  antisepsis,  and  nature  will  take  care  of  the  rest.  In  cer- 
tain of  the  joints,  however,  mere  incision  may  not  be  sufficient  and 
excision  must  be  added. 


Fig.   339- — Septic  arthritis.      Incisions  for  drainage  of  the  knee.      {Veau.) 

Arthrotomy  of  the  Knee. — Sepsis  affecting  the  knee-joint  causes  the 
knee  to  become  enlarged,  globular  in  outline,  painful,  reddened, 
edematous,  with  constitutional  symptoms  of  sepsis.  The  operation, 
under  general  anesthesia,  is  very  simple  and  without  danger.  The 
important  thing  is  to  open  freely.  Two  incisions  are  to  be  made,  one 
external  and  one  internal  (Fig.  339). 

External  Incision. — ^Locate  the  lower  border  of  the  patella;  and,  be- 


442 


SEPTIC   ARTHRITIS 


ginning  a  little  below  this  line,  make  an  incision  parallel  with  the 
external  border  of  the  patella  and  ending  about  two  fingers'  breadth  ^ 
above  its  upper  border,  which  will  be  near  the  upper  limit  of  the  syno- 
vial sac.  This  incision  traverses  the  integument  and  beneath  it  the 
firm  aponeurosis  of  the  vastus  externus.  As  the  joint  cavity  is 
reached,  very  often  the  pus  spurts  out  with  great  force. 


Fig.   340. — Drawing  the  transverse  drain  into  place.      (Veau.) 

Internal  Incision.— On  the  inside,  make  an  incision  symmetrical 
wdth  the  first,  but  a  little  further  removed  from  the  internal  border  of 
the  patella.  The  aponeurosis  is  here  less  firm,  but  the  synovial 
cavity  is  deeper;  the  swelling  is  usually  greater  on  the  inner  side. 
Some  of  the  fleshy  fibers  of  the  vastus  internus  are  always  divided. 
The  cavity  is  not  so  easily  reached  as  on  the  outer  side. 

Drainage.— Plsice  a  large  transverse  drain  (Fig.  340).  But  in  some 
cases  this  is  not  sufficient.  The  lateral  diverticula  of  the  synovial 
sac  must  be  drained  separately  (Fig.  341).  For  this  two  counter- 
openings  are  required,  one  on  each  side.  Into  one  of  the  incisions 
at  its  lower  part,  introduce  forceps,  and  push  backward  and  downward 
through  the  synovial  sac  at  the  level  of  the  interarticular  line  (Fig. 


ARTHROTOMY    OF    TIIK   KNEE 


443 


Aflf^ 


Fig.  341. — Cross  section  of  knee-joint  showing  that  the  transverse  tube  drains  the  upper 
part;  the  two  lateral  tubes  the  inferior  part  of  the  synovial  sac.      {yeau^ 


Fig.  342. — Manner  of  making  posterior  counter- opening  for  rainage  of 
the  knee.    (TeoM.) 


444 


SEPTIC   ARTHRITIS 


342).  If  it  is  an  old  arthritis,  this  is  not  difficult;  but  in  the  case  of 
a  recent  effusion,  the  ligaments  are  tense,  and  the  articular  surfaces 
are  in  contact  so  that  the  passageway  is  quite  narrow. 

When  the  forceps,  pushed  backward  in  this  manner,  bulges  the 
skin,  open  the  blades,  and,  between  them,  make  an  incision  i  or 
2  inches  long.  Through  this  opening  in  the  forceps,  draw  a  drain- 
a^^e-tube  into  place.     Repeat  the  maneuver  on  the  opposite  side. 


1 


Fig.   3^3- — Septic  arthritis.      Drainage  ot  the  knee  complete.      iVeau.) 

It  is  better  to  make  the  counter-opening  on  the  external  side  first, 
as  the  ligaments  there  are  less  tense.  The  beginner  is  seldom  success- 
ful in  making  the  opening  internally.  He  nearly  always  pushes  the 
forceps  backward  at  too  high  a  level  and  the  point  engages  in  the 
tendon  of  the  adductor  magnus.  It  must  be  directed  downward  and 
backward  (Fig.  343).  When  the  joint  is  thus  opened,  irrigate  freely 
with  hot  saline  solution,  reaching  every  recess  of  the  joint  and  wiping 
with  sterile  gauze.     Aim  to  clean  the  whole  synovia.     If  the  joint 


PUNCTURE    OF   THE   KNEE 


445 


is  putrid,  finish  tlic  irrigation  with  peroxide.  Do  not  suture  the 
wounds.  Employ  a  moist  antiseptic  dressing.  ImmobiHze  the 
limb  on  a  posterior  plaster  splint. 

Subsequent  Treatment. — Irrigate  and  dress  twice  daily  for  the  first 
few  days.  However,  if  the  temperature  falls  almost  to  normal  and 
the  pain  ceases,  do  not  be  in  a  hurry  to  change  the  first  dressing. 


Fig.  344. — Puncture  of  the  knee.  (Lejars.) 
Occasionally  it  is  desirable  to  empty  the  knee-joint,  as  in  the  case  of  a  voluminous 
hemarthrosis  or  serous  exudation.  The  same  careful  asepsis  is  practised  as  for  arthrot- 
omy.  Locate  the  upper  external  angle  of  the  patella.  A  little  above  and  to  the  out- 
side of  this  point,  plunge  the  trocar  directly  into  the  joint.  The  structures  here  are  quite 
resistant,  but  there  are  no  vessels  likely  to  be  wounded.  As  the  exudate  flows  out,  gently 
compress  the  joint  to  empty  it.  Withdraw  the  trocar  with  a  quick  movement,  apply  a 
sterile  dressing,  and  bandage  the  knee  in  absorbent  cotton. 


If  the  suppuration  diminishes  about  the  end  of  the  first  week,  put 
in  a  smaller  drain  in  the  same  manner  as  before,  and  employ  dry 
dressings.  Watch  the  temperature.  A  rise  indicates  a  retention  of 
pus  and  calls  for  new  drainage.  Endeavor  to  avoid  permanent 
flexion  of  the  knee,  a  matter  of  the  greatest  difficulty  and  of  the 
greatest  importance,  for  such  flexion  cannot  be  corrected. 


446 


SEPTIC   ARTHRITIS 


After  the  second  week  the  lateral  drains  are  removed;  and,  some 
days  later,  the  transverse  drain.  After  a  month,  if  the  inflammation 
is  all  gone,  attempt  passive  motion;  but  it  is  almost  a  certainty  that 
the  joint  will  be  stiff;  still  if  it  is  stiffened  in  extension,  there  is  no 
occasion  for  reproach. 


Fig.  345- — Arthrotomy  of  the  ankle.      Trace  of  the  incisions.      {Veau.) 


ARTHROTOMY  OF  THE  ANKLE-JOINT 

This  operation  is  not  so  frequently  required  as  for  the  knee.  Often 
local  anesthesia  will  suffice.  Make  the  first  incision,  2  inches  in 
length,  over  the  anterior  border  of  the  external  malleolus  and  reach- 
ing a  httle  below  its  tip  (Fig.  345).  In  the  upper  part  of  the  incision, 
one  may  cut  freely  down  to  the  bone,  but  in  the  lower  part  more  care 
must  be  used.  Some  small  arteries  may  be  divided  if  one  goes  too 
deep. 

In  the  middle  of  the  incision,  open  the  joint,  enlarge  the  orifice, 
and  mop  out  the  cavity. 

Introduce  an  artery  forceps  and  carry  it  through  the  joint  cavity 
to  the  opposite  side,  and  over  its  point  make  a  counter-opening  (Fig. 
346).     This  opening  should  fall  over  the  tip  of  the  inner  malleolus. 


ARTHROTOMY   OF   THE   ELBOW 


447 


As  the  forceps  is  withdrawn,  it  pulls  a  drainage-tube  into  place  (Fig. 

347)- 

Dressing  and  subsequent  care  are  the  same  as  in  the  knee. 

ARTHROTOMY  OF  THE  ELBOW- JOINT 

Make  a  vertical  incision  3  inches  in  length,  with  its  center  over 
the  outer  border  of  the  apex  of  the  olecranon,  dividing  some  of  the 


Fig.  346. — Septic  arthritis.      Drainage  of  ankle-joint.      (Feaw.) 

fibers  of  the  triceps  and  anconeus  (Fig.  348).  Puncture  the  synovial 
cavity  at  the  middle  of  the  incision  and  enlarge  the  opening  to  corre- 
spond with  the  incision.  Push  a  forceps  transversely  through  the 
joint  at  the  upper  level  of  the  olecranon.  Over  its  point  make  the 
internal  vertical  incision.  Cut  carefully,  for  the  ulnar  nerve  is  here 
in  close  contact  with  the  posterior  surface  of  the  inner  condyle. 

Draw  a  drain  into  place  with  the  forceps.     The  dressing  and  sub- 
sequent care  is  the  same  as  that  described  for  the  knee. 


448 


SEPTIC    ARTHRITIS 


ARTHROTOMY  OF  THE  WRIST 

i\Iake  an  external  incision  between  the  long  extensors  of  the  thumb 
and  the  extensors  of  the  index-finger,  lines  which  may  always  be 
determined.  Make  a  second  incision  on  the  ulnar  side  between  the 
tendons  of  flexor  and  extensor  carpi  ulnaris.  The  two  incisions  may 
be  connected  by  pushing  a  grooved  director  through. 


Fig.  347. — Septic  arthritis  of  ankle.      Drainage  placed.      (,Veau.) 

ARTHROTOMY  OF  THE  SHOULDER 

This  joint  may  be  opened  by  a  vertical  incision,  beginning  at  the 
anterior  angle  of  the  acromion  process  and  cutting  downward  in  the 
line  of  the  bicipital  groove,  or  the  joint  may  be  opened  behind  along 
the  posterior  border  of  the  deltoid,  splitting  the  tendons  of  the  in- 
fraspinatus and  teres  minor. 

ARTHROTOMY  OF  THE  HIP 

The  hip-joint,  deeply  set  under  a  thick  muscular  mass,  may  be 
reached  either  from  in  front  or  behind.     The  aim  of  any  procedure  is 


ARTHROTOMY   OF    THE   IHP 


449 


to  reach  the  articulation  in  such  manner  as  to  produce  the  least  de- 
struction possible  in  these  periarticular  muscles;  and,  therefore,  one 
must  seek  the  intermuscular  spaces,  or  split  the  various  muscles  in 
the  direction  of  their  fibers. 

The  study  of  the  anatomy  of  the  region  demonstrates  that  several 
pathways  to  the  joint,  complying  with  the  above  conditions,  can  be 
found. 

In  front,  the  joint  is  covered  by  several  muscles  whose  directions 
correspond  to  the  axis  of  the  thigh — -the  pectineus,  the  iliopsoas,  the 


--//</' 


Fig.  348. — Septic  arthritis  of  elbow.     Incisions  for  drainage.     {Veau.) 


rectus  femoris,  in  direct  contact  with  the  capsule;  the  sartorius  and 
the  fascia  lata  more  superficially  placed. 

Behind,  the  joint  lies  under  a  group  of  muscles  which  are  parallel  to 
it  when  flexed  at  an  angle  of  45°.  These  are  arranged  in  two  layers; 
in  the  first,  the  g.  maximus;  in  the  second,  the  g.  medius  and  the  ob- 
turator internus  and  gemelli;  while  below  and  behind  is  the  tendon 
of  the  obturator  externus. 

ANTERIOR  ARTHROTOMY. — -If  One  wishes  to  rcach  the  joint  from  in 
front,  he  may  pass  (i)  in  between  the  fascia  lata  and  the  gluteus 
medius  externally  and  the  rectus  and  sartorius  internally. 
29 


450  SEPTIC  ARTHRITIS 

(2)  Between  the  rectus  and  sartorius  externally  and  psoas  in- 
ternally. 

(3)  Through  the  sheath  of  the  psoas. 

In  the  first  case,  the  outer  end  of  the  neck  and  the  great  trochanter 
is  exposed.  In  the  second,  the  inner  end  of  the  neck,  and  in  the  third, 
the  head  of  the  femur. 

Position. — On  the  back  with  legs  extended.  Operator  stands  at 
outside  with  assistant  opposite,  and  second  assistant  moves  the  leg 
as  directed. 

Incision. — (i)  Incision  begins  above,  and  finger's  breadth  inside,  of 
ant.  sup.  spine,  and  extends  downward  and  inward  parallel  to  the  sar- 
torius, for  4  inches.  Expose  the  internal  border  of  sartorius,  draw  it 
outward.  Below  it  will  be  exposed  the  rectus  to  be  drawn  outward 
also.     The  psoas  is  exposed  and  drawn  inward  to  expose  the  capsule. 

(2)  The  incision  begins  directly  over  the  ant.  sup.  spine,  and  de- 
scends nearly  vertically,  bisecting  the  angle  between  the  sartorius 
and  tensor  fascia  lata.  The  sartorius  and  rectus  are  drawn  inward 
and  the  capsule  exposed. 

(3)  Finally,  the  incision,  to  follow  the  outer  border  of  the  psoas, 
may  begin  at  the  inner  third  of  Poupart's  ligament  and  extend  down- 
ward and  shghtly  inward.  The  psoas  is  exposed  near  its  inner  border 
and  opened,  avoiding  the  anterior  crural  nerve. 

Open  the  Capsule. — Once  the  capsule  is  exposed,  whatever  the 
route,  the  muscles  are  to  be  relaxed  by  flexion,  abduction,  and  exter- 
nal rotation  which  favors  their  retraction.  The  capsule  thus  freely 
exposed  is  incised  to  any  extent  necessary. 

Counter-opening  in  Capsule. — It  may  be  advisable  to  make  an  in- 
ternal incision  to  secure  complete  drainage.  Make  an  incision  from 
the  external  border  to  the  pubes  downward  and  outward,  exposing 
the  space  between  the  pectineus  and  adductor  longus.  Avoid  the 
obturator  nerve.  Next  introduce  a  forceps  into  the  opening 
already  made  in  the  capsule  and  let  the  point  emerge  at  the  second 
opening;  and,  on  this  point  as  a  guide,  the  counter-opening  is  made. 
The  forceps  is  used  to  draw  a  large  drainage-tube  into  place. 


CHAPTER  XXI 
FOREIGN  BODIES 

THE  EYE 

Foreign  bodies  lodged  on  the  conjunctiva  or  cornea  are  painful,  and 
may  soon  provoke  a  conjunctivitis,  more  or  less  severe. 

The  offending  particle  may  be  concealed  under  the  lid  or  be  im- 
bedded in  the  cornea.  The  latter  is  especially  likely  to  be  the  case 
with  those  who  have  to  do  with  emery  wheels. 

The  patient's  sensation  is  a  very  poor  guide  in  locating  the  object; 
if  it  is  on  the  cornea,  he  is  likely  to  be  certain  it  is  under  the  upper 
lid. 

Begin  by  inspecting  the  eye  under  a  good  light  and  at  various  angles. 
Pull  down  the  lower  lid,  instructing  the  patient  to  look  upward. 
Evert  the  upper  lid.  This  is  done  by  grasping  the  eye-lashes  be- 
tween the  thumb  and  fore-finger  and  pulling  downward,  at  the  same 
time  making  pressure  upon  the  tarsal  cartilage  of  the  lid  with  a  pen- 
cil, stylet,  or  the  opposite  thumb.  Instruct  the  patient  to  look 
downward.  Combined  with  this  pressure,  the  eyelashes  are  now 
pulled  upward  and  in  this  manner  the  lid  is  everted  and  exposed 
to  inspection.  The  novice  does  better,  perhaps,  to  stand  behind  the 
patient,  but  the  specialist  sits  in  front  of  the  patient  and  turns  the 
lid  with  one  hand. 

If  the  foreign  body  is  free,  it  is  readily  picked  up  with  the  point  of 
the  stylet  wrapped  with  cotton,  but  if  it  is  imbedded  in  the  cornea,- 
considerable  curettement  may  be  required  to  dislodge  it.  The  in- 
strument must  be  sterile,  otherwise  corneal  ulcer  may  follow  the 
manipulation.  In  the  case  of  nervous  or  sensitive  individuals  or 
when  the  conjunctiva  is  much  congested,  the  manipulation  must  be 
preceded  by  the  instillation  of  a  few  drops  of  a  4  per  cent,  solution  of 
cocaine,  which  should  be  fresh  and  must  be  sterile.  Everything  used 
must  be  sterile — hands,  instruments,  cotton,  and  solutions. 

451 


452  FOREIGN  BODIES 

Following  the  extraction,  irrigate  with  normal  salt  solution  and  in- 
still two  drops  of  2  per  cent,  collargolum  solution  or  lo  to  25  per  cent, 
argyrol  solution  and  direct  the  patient  to  wash  the  eye  frequently 
with  boracic  or  normal  salt  solution;  if  there  is  much  congestion,  band- 
age the  eye  for  one  or  two  days. 

If  the  foreign  body  has  penetrated  to  the  anterior  chamber,  the  iris, 
or  the  posterior  chamber,  the  immediate  treatment  must  be  limited 
to  such  measure  as  will  prevent  infection — boracic  irrigation  and 
bandage — until  the  case  can  be  placed  in  the  hands  of  a  specialist  or 
until  special  text-books  can  be  carefully  consulted. 

It  may  be  necessary  to  employ  the  X-ray  in  diagnosis  in  these 
cases.  The  extraction  may  require  a  delicate  operation  or  the  use  of 
the  electro-magnet,  and  finally  the  removal  of  the  globe  may  be 
necessary. 

Chemical  irritants  should  be  removed  by  free  irrigation.  For 
lime  in  the  eye,  a  solution  of  sugar  in  vinegar  is  recommended,  the 
sugar  forming  a  soluble  compound  -^^th  the  lime.  A  few  drops  are 
used,  followed  by  free  flushing  with  water.  Afterward  atropine, 
gr.  I  to  the  ounce  is  imperatve. 

THE  EAR 

The  foreign  bodies  most  frequently  found  in  the  ear  are  pebbles, 
shoe-buttons,  peas,  beans,  pens,  pieces  of  tooth-pick,  pieces  of  cotton, 
etc.,  etc. 

Children  may  place  these  objects  in  their  ears  in  play  or  innocent 
experimentations  or  adults  may  meet  with  the  accident,  attempting 
to  relieve  an  itching  in  the  auditory  canal.  A  tampon  may  be  left 
in  the  ear  by  the  doctor.  The  body  usually  lodges  in  the  outer  part 
of  the  canal,  and  only  reaches  the  tympanic  membrane  after  ill- 
advised  efforts  at  extraction. 

The  pain  and  discomfort  are  usually  moderate;  and,  as  a  rule,  there 
are  no  very  urgent  indications  for  intervention.  But  if  the  object 
rests  against  the  drum,  the  pain  is  severe  and  may  even  produce 
mental  disturbance. 

The  first  thing  to  do,  then,  is  always  to  confirm  the  diagnosis.  The 
patient's  belief  in  the  matter  must,  imder  no  circumstances,  be  ac- 


FOREIGN  BODIES   IN   THE   EAR  453 

cepted  as  final.  There  is  only  one  way  to  confirm  the  diagnosis  and 
that  is  by  careful  inspection  of  the  whole  canal,  if  the  object  is  not 
seen  in  the  outer  portion. 

Draw  the  external  ear  upward  and  backward,  and  the  tragus  for- 
ward. Under  good  illumination  and  with  the  aid  of  a  head-mirror 
and  otoscope,  the  drum  is  readily  seen.  If  no  foreign  body  can  be 
seen,  and  provided  there  have  been  no  blind  efforts  at  extraction,  it 
may  be  definitely  concluded  that  the  patient  is  mistaken. 

If,  on  the  other  hand,  you  locate  the  object,  do  not  hurriedly  intro- 
duce a  forceps  into  the  ear;  unless,  indeed,  the  offending  body  is  of 
such  a  nature  that  it  may  be  easily  seized,  for  you  will  almost  always 
make  matters  worse,  pushing  it  further  into  the  canal.     Remember 


Fig.  349. — Ear  forceps. 

that  however  desirable  it  may  be  to  empty  the  ear,  there  is,  as  a  rule, 
no  great  urgency  in  the  matter  and  you  have  plenty  of  time  to  take 
counsel  with  yourself  (Fig.  349). 

In  some  cases,  a  small  hooked  instrument  may  be  cautiously 
pushed  past  the  object  and  withdrawn,  pulling  the  object  out,  or  a 
small  blunt  curette  may  be  similarly  employed.  Usually  a  large 
syringe  is  the  proper  instrument.  Throw  a  stream  of  warm,  sterile 
water  into  the  ear  with  the  purpose  of  forcing  the  body  out  by  the 
"m  a  tergo.^^ 

To  inject  the  stream  properly,  Uf  t  the  pinna  upward  and  backward 
asin  inspection,  and  direct  the  stream  along  the  posterior  superior 


454  FOREIGN  BODIES 

wall,  using  moderate  force.  Use  one  syringeful  after  another,  until 
the  offending  substance  is  washed  away  or  the  patient  is  tired  out. 

If  you  have  failed,  instill  into  the  ear  a  few  drops  of  glycerine  or 
warm  oil,  lightly  tampon,  and  direct  the  patient  to  sleep  on  the 
affected  side,  returning  the  next  day  for  another  trial.  The  chances 
are  greatly  in  favor  of  ultimate  success  without  injury  to  the  ear. 

In  the  case  of  a  live  insect  in  the  ear,  fill  the  ear  with  oil  and  sub- 
sequently the  "cadaver"  may  be  removed  by  irrigation. 

If  ''instrumentation"  seems  advisable,  there  must  be  no  blind 
grasping  for  the  object — it  must  be  kept  clearly  in  view.  It  has 
happened,  in  violation  of  this  rule,  that  the  middle  ear  has  been  in- 
vaded and  the  ossicles  dragged  out.  Death  has  occurred  from  such 
manipulation,  though  the  post-mortem  showed  that  no  foreign  body 
had  ever  been  present. 

In  the  case  of  children,  instrumental  extraction  will,  as  a  rule,  re- 
quire an  anesthetic.  If  the  ear  has  become  much  inflamed  or  the 
body  pushed  through  the  drum,  the  case  is  one  for  the  specialist. 

On  the  w^hole,  the  practitioner  might  adopt  the  rule,  that  if  left  in 
the  ear,  untouched,  the  foreign  body  is  less  Hkely  to  do  harm  than 
rude  and  maladroit  efforts  at  removal. 

THE  NOSE 

The  catalogue  of  bodies,  recorded  as  lodged  in  the  nose,  is  long. 
Naturally,  children  are  more  frequently  the  subject  of  these  mishaps 
although  lunatics  and  hysterical  women  may  intentionally  plug  the 
nose.  Occasionally,  a  foreign  body  previously  swallowed,  may  be 
coughed  up  and  lodge  in  the  posterior  nares.  Pledgets  of  cotton  and 
pieces  of  gauze,  which  have  been  used  as  tampons,  may  be  over- 
looked and  act  as  foreign  bodies. 

In  the  case  of  the  irresponsible,  the  presence  of  a  foreign  body  may 
not  be  suspected,  so  few  are  the  symptoms,  until  there  develops  a 
profuse  sero-mucous  discharge.  There  may  be  frequent  attacks  of 
sneezing;  and,  if  the  body  remains  long,  the  mucous  membranes  be- 
come swollen  and  perhaps  the  skin  of  the  affected  side  also.  There 
may  be  headache  or  facial  neuralgia.  These  foreign  bodies  should  be 
removed  as  soon  as  possible,  first  having  determined  their  nature, 
size,  and  situation. 


FOREIGN  BODIES  IN  THE  PHARYNX  455 

Begin  by  a  careful  examination  of  the  anterior  nares;  and,  if  this 
is  not  sufficiently  instructive,  examine  the  posterior  nares  by  hooking 
the  finger  up  behind  the  soft  palate.  The  examination  and  removal 
are  often  facilitated  by  the  use  of  cocaine,  and  in  the  case  of  children, 
a  few  whiffs  of  chloroform  may  be  necessary. 

Chloroform  is  also  the  effectual  remedy  for  animate  foreign  bodies, 
such  as  insects  and  maggots.  Used  for  this  purpose,  it  is  not  inhaled, 
but  is  shaken  up  with  an  equal  amount  of  water  and  syringed  into  the 
nose  before  the  two  ingredients  separate. 


Fig.  350. — Angular  forceps  for  foreign   body  in  the  nose. 

A  body  lying  in  the  anterior  nares  is  usually  readily  removed  by  a 
mouse-toothed  forceps;  or  a  curved  probe  or  small  curette  may  be 
necessary  to  dislodge  it.  An  angular  forceps  is  sometimes  conven- 
ient (Fig.  350).  In  other  cases,  the  obstruction  may  be  removed 
by  drawing  a  tampon  through  the  nasal  cavity  from  behind,  as  recom- 
mended by  Sajous. 

If  the  body  is  lodged  in  the  posterior  nares,  it  is  usually  pushed 
backward  into  the  pharynx,  care  being  taken  that  it  does  not  drop 
down  into  the  larynx  or  esophagus. 

"In  the  case  of  infants,  a  small  body  may  be  removed  by  blowing 
forcibly  into  the  mouth."     (John  J.  Kyle.) 

PHARYNX  AND  ESOPHAGUS 

Many  diverse  objects  may  lodge  in  these  passageways,  either 
through  ineffectual  efforts  at  swallowing  or  by  inadvertently  sHpping 


456  FOREIGN  BODIES 

from  the  mouth.  False  teeth  are  often  loosened  and  carried  into  the 
pharynx  or  esophagus  during  sleep. 

The  point  of  lodgment,  the  immediate  effect,  the  dangers,  and 
the  difficulty  of  removal,  depend  upon  the  size  and  shape  of  the 
object. 

The  pharyngo-esophageal  canal  is  narrowest  behind  the  larynx, 
opposite  the  cricoid  cartilage  and  the  sixth  cervical  vertebra;  at  this 
point  a  large  body  is  hkely  to  lodge.  A  second  constriction  lies 
2%  inches  further  down,  behind  the  left  bronchus;  and  a  third 
where  the  esophagus  passes  through  the  diaphragm.  Larger 
bodies,  then,  are  liable  to  lodge  opposite  the  larynx.  Sharp 
and  pointed  objects,  such  as  needles  and  fishbones,  may  anchor  at 
any  point  ^dthout  reference  to  the  caliber  of  the  conduit. 

The  immediate  effects  of  the  lodgment  of  a  foreign  body  vary 
from  instant  asphyxia  to  merely  slight  difficulty  in  swallowing. 
Later  there  may  occur,  even  in  the  case  of  a  sHght  obstruction,  the 
dangerous  conditions  following  infection — erosion  of  the  walls, 
perforation  of  the  bronchi  or  lungs,  of  the  pericardium,  the  aorta,  or 
carotids — one  has  but  to  think  of  the  numerous  relations  of  the 
esophagus  in  the  neck  and  thorax  to  understand  how^  diverse  the 
consequences  of  such  spreading  infection  might  be  in  various  cases. 

Ver}^  naturally,  the  deeper  down  the  object  lodges,  the  greater 
the  difficulty  in  locating  and  reaching  it. 

Treatment. — -Asphyxia,  due  to  occlusion  of  the  lower  part  of  the 
pharynx  involving  the  larynx,  demands  immediate  action.  The 
patient  is  livid,  gasping,  and  struggling.  Run  the  finger  into  the 
throat  over  the  epiglottis,  where  the  body  may  be  felt  and  hooked 
out.  If  you  fail  in  this,  do  not  waste  time  in  these  cases  of  extreme 
urgency,  tr}'ing  tentative  measures,  such  as  inversion,  but  do  a 
tracheotomy,  or  lar3-ngotomy  in  the  adult  (see  page  477).  After  the 
operation,  the  foreign  body  may  be  expelled  spontaneously  in  the 
efforts  of  coughing  or  vomiting. 

In  the  less  urgent  cases,  the  first  indication  is  to  confirm  the  diag- 
nosis and  definitely  locate  the  object.  The  sensation  of  the  patient 
is  not  sufficient  index  as  to  the  presence  and  situation  of  an  obstruc- 
tion in  the  gullet,  for  the  pain  may  be  due  to  a  wound  made  by  the 
foreign  body  in  passing. 


FOREIGN  BODIES   IN   THE    ESOPHAGUS 


457 


Inspect  the  mouth,  the  fauces,  and  the  tonsils.  Palpate  the  region 
of  the  glottis  and  behind  the  soft  palate.  Palpate  externally  along 
the  anterior  border  of  the  sternomastoid,  pressing  deeply  to  reach  the 
esophagus,  most  superficial  on  the  left  side.  Even  if,  as  a  result  of 
this  palpation,  the  foreign  body  is  believed  to  be  located  in  the  neck, 
it  is  better  to  make  certain  by  passing  an  esophageal  sound. 

In  certain  instances,  the  X-ray  will  be  invalu- 
able, though  not  always  to  be  relied  upon.  In 
the  hands  of  the  expert,  the  esophagoscope  has 
proved  to  be  useful.  In  the  course  of  time  this 
instrument  will  probably  come  to  be  a  part  of 
every  doctor's  ''arsenal."  It  not  only  makes 
exact  diagnosis  possible,  but  enables  the  foreign 
body  to  be  removed  by  sight,  avoiding  thus  the 
injuries  to  the  esophagus  which  blind  efforts 
often  produce. 

The  presence  and  location  of  the  foreign 
body  once  established,  extraction  is  indicated. 
Inversion  is  illusory  and  emesis  dangerous. 

If  the  body  is  in  the  pharynx,  it  may  be  seized 
with  curved  forceps,  or  dislodged  with  the  finger 
or  an  improvised  hook.  To  employ  the  forceps, 
seat  yourself  before  the  patient,  w^hose  mouth 
is  propped  wide  open.  When  the  object  is 
once  seized,  incline  the  patient's  head  forward 
as  the  forceps  is  withdrawn.  If  you  lose  your 
hold,  rapidly  withdraw  the  forceps  and  remove 
the  mouth  gag  and  often  the  loosened  object  will  be  coughed  out. 

In  the  case  of  an  infant,  place  the  patient  on  its  back  with  the  head 
hanging  over  the  edge  of  the  table,  thus  preventing  the  body  from 
dropping  into  the  larynx.     (Have  everything  ready  for  tracheotomy.) 

In  extracting  a  body  from  the  esophagus,  the  greatest  caution  is 
necessary  to  prevent  laceration.  Rough  manipulation  only  aggra- 
vates the  miiscidar  spasm,  which  is  always  present  in  some  degree, 
and  which,  more  than  anything  else,  prevents  the  body  safely  reach- 
ing the  stomach;  and  these  esophageal  muscles  are  exceedingly  strong. 
The^esophageal  forceps  is  used  as  in  the  pharynx. 


Fig.  351. — Horse- 
hair probang.  Open 
and   closed. 


458 


FOREIGN  BODIES 


The  horse-hair  probang  (Fig.  351),  introduced  past  the  object, 
opened  up  and  then  withdrawn,  often  succeeds  in  removing  an  im- 
planted needle  or  fish  bone. 


Fig.  352. — Coin  catchers. 

In  the  case  of  a  coin  or  similarly  shaped  object  a  "coin  catcher" 
may  be  employed  (Fig.  352).  Introduce  the  left  indexfinger  as  a 
guide  and  pass  the  instrument  along  its  posterior  wall  until  the  coin 
is  felt,  when  the  catcher  is  passed  on  beyond  it.  Now  tilt  the  handle 
forward  and  slowly  withdraw  the  instrument  until  assured  by  the 

sense  of  touch  that  the  coin  is  engaged. 
Completely  withdraw  the  instrument 
by  steady,  continuous,  vertical  trac- 
tion. When  the  pharyngeal  orifice  is 
reached,  it  is  necessary  to  accelerate 
the  movement  to/achieve  the  final  ex- 
traction (Fig.  353). 

If,  in  the  course  of  the  manipulation, 
the  foreign  body  is  dislodged  and  shps 
on  down  into  the  stomach,  do  not  re- 
gard it  as  a  calamity,  unless  the  object 
is  very  pointed.  Indeed,  if  the  object 
is  deeply  located,  is  known  to  be  harm- 
less in  character,  and  extraction  seems 
impossible,  an  effort  should  ';be  made 
from  the  first  to  push  it  on  into  the 
stomach  with  the  esophageal  bougie. 
This  should  never  be  done,  if  the 
character  of  the  substance  is  unknown.  No  effort  should  be  pro- 
longed and  above  all  else,  no  violence,  is  permissible.  Finally,  if 
extraction  fails  and  propulsion  into  the  stomach  is  out  of  the  ques- 
tion, there  is  only  one  thing  left  to  be  done — an  esophagotomy. 


Fig.  353. — Extracting  a  coin  from 
the  esophagus.     (Lejars.) 


FOREIGN   BODIES   IN   THE   ESOPHAGUS  459 

In  certain  cases  where  the  body  is  firmly  implanted,  or  when  it  is 
pointed  and  dangerous  to  move,  resort  must  be  made  to  the  operation 
at  once  (see  page  484). 

LARYNX  AND  TRACHEA^ 

The  air  passage  is  frequently  involved,  an  accident  always  of  con- 
cern, often  serious,  and  sometimes  fatal. 

The  bodies  finding  their  way  into  the  larynx  and  trachea  are  of 
great  variety,  fluid  and  solid,  animate  and  inanimate;  most  often 
aliments  perhaps,  and  after  these,  the  list  may  be  indefinitely  ex- 
tended. 

Children  are  more  often  sufferers,  because  of  their  habit  of  putting 
objects  into  their  mouths  at  random.  Many  times  particles  of  food 
''go  the  wrong  way,"  the  result  of  the  patient's  speaking  or  laughing 
during  the  act  of  swallowing:  the  epiglottis  is  raised  inopportunely, 
and  the  morsel  drops  into  the  larynx.  Small  bodies  are  inhaled  in 
ordinary  breathing.  The  accident  sometimes  happens  during  sleep, 
through  the  dislodgment  of  false  teeth  or  something  held  in  the 
mouth;  it  may  follow  an  attack  of  vomiting,  or  it  may  occur  during 
some  operation  about  the  mouth;  conditions  such  as  anesthesia, 
which  diminish  the  reflex  irritability  or  motility  of  the  larynx,  favor 
it. 

The  point  of  lodgment  depends  chiefly  upon  the  size  and  shape  of 
the  object.  Pointed  objects,  such  as  pins  and  fishbones,  frequently 
stick  in  the  supraglottic  portion  of  the  larynx;  flat  bodies,  coins  and 
buttons,  usually  lodge  in  the  ventricles,  while  small  globular,  heavy 
bodies  descend  into  the  trachea  or  bronchus,  usually  the  right. 

The  symptoms  and  sequelae,  and  therefore  the  dangers,  may  be 
grouped  under  two  heads,  obstructive  and  inflammatory. 

(a)  If  the  body  is  large  and  lodged  in  the  larynx,  a5^/fyA;m  may  be 
the  immediate  result  and  may  be  almost  immediately  fatal.  Even 
small  bodies  may  produce  fatal  asphyxia  through  reflex  spasm  of  the 
glottis,  though  usually  the  reflex  spasm  subsides.  Reflexly,  also, 
coughing,  sometimes  violent,  is  induced,  and  this  may  be  the  case 
whether  the  body  lies  in  the  larynx,  trachea,  or  bronchus.     Some- 

1  Quotations  are  from  Von  Bergman. 


460  FOREIGN  BODIES 

times  the  body  may  lodge  between  the  vocal  cords,  thus  preventing 
their  closure  and  allowing  some  air  to  pass  so  that  life  may  be  sus- 
tained for  some  time. 

If  the  body  is  lodged  in  the  ventricles,  there  may  not  be  so  much 
obstruction,  but  there  is  hoarseness  or  aphonia  and  cough. 

If  the  body  descends  into  the  trachea,  there  may  be  no  indication 
of  obstruction,  but  there  is  much  reflex  irritation,  evidenced  by  pain 
and  cough.  If  the  body  is  light,  it  may  move  backward  and  forward 
in  the  trachea,  following  the  current  of  air. 

If  a  bronchus  is  obstructed,  a  whole  or  a  portion  of  the  lung  may 
collapse,  evidenced  by  altered  auscultatory  sounds. 

(b)  The  body  may  become  encysted  if  not  removed,  or  inflamma- 
tion may  ensue  with  the  most  diverse  sequences,  depending  upon  the 
location  of  the  object:  edema  of  the  glottis,  diphtheritic  inflamma- 
tion, abscess  of  the  larynx,  phlegmon  of  the  neck,  hemorrhage  due  to 
erosion  of  the  large  vessels  or  even  of  the  heart,  tracheitis,  bronchitis, 
bronchiectasis,  pneumonia,  gangrene  of  the  lung,  empyema,  purulent 
pericarditis,  mediastinitis,  or  phthisis. 

Treatment. — Asphyxia  demands  immediate  action;  there  is  no  time 
for  examination  and  inquiry.  Make  a  hurried  effort  to  remove  the 
body  by  passing  the  finger  into  the  larynx,  and  if  this  fails,  without 
further  delay  do  a  tracheotomy  (see  page  481). 

In  the  less  urgent  cases,  one  may  be  more  deliberate,  endeavoring 
to  ascertain  the  character  of  the  object  and  to  locate  the  point  of 
lodgment.  The  history  of  the  case,  the  symptoms  and  the  physical 
signs  derived  from  auscultation,  will  furnish  valuable  information. 

Various  procedures  are  recommended. 

"Inversion  and  violent  shaking  of  the  body  do  not  enjoy  their 
former  popularity.  Even  the  conservative  Weist  considers  manipu- 
lation of  this  sort  dangerous  and  only  justifiable  after  tracheotomy." 

StiU  it  does  not  seem  likely  that  it  can  result  in  harm  if  the  body 
is  known  to  be  small  so  that  it  may  readily  pass  between  the  vocal 
cords. 

''The  simplest  way  is  to  follow  the  suggestion  of  Sanders,  and  let 
the  body  hang  over  the  edge  of  the  bed  and  rest  on  the  hands  during 
the  attack  of  coughing."  "Generally  speaking,  emetics  are  unre- 
liable and  their  use  not  without  danger." 


BRONCHOSCOPY 


461 


If  there  is  time,  the  laryngoscope  may  be  of  great  aid  in  diagnosis 
and  extraction,  employing  cocaine  in  the  adult  and  chloroform  in 
children.  ^— ^ 

In  the  hands  of  the  skilled,  the  broncho- J 
scope  often  furnishes  a  happy  solution  to  ""^ 
the  difficulty  (Fig.  354).  It  is  to  be  hoped 
that  the  technic  of  bronchoscopy,  now 
familiar  only  to  the  specialists,  will  soon 
be  popularized  with  the  profession  at 
large.  In  cases  less  urgent,  the  X-ray 
may  be  used  to  locate  the  substance. 

But  after  all,  tracheotomy  or  laryngot- 
omy  is  the  chief  reliance  of  the  practitioner 
left  to  his  own  resources,  and  he  must  be 
prepared  for  immediate  operation  while 
other  measures  are  tentatively  tried' 
Lejars  urges  that  an  attendant  be  at  hand 
ready  for  instant  operation  as  long  as  the 
body  is  known  to  be  free  in  the  bronchus 
or  trachea. 

''It  makes  no  difference  what  one's 
views  are  regarding  tracheotomy  in  gen- 
eral; the  fact  remains  that  no  physician 
will  deny  the  necessity  of  this  step  when 
the  danger  of  suffocation  is  great." 

"The  author  has  become  convinced  that 
the  danger  of  tracheotomy  nowadays  is 
insignificant  compared  with  that  of  a 
foreign  body  in  the  air  passages  and  does 
not  hesitate,  even  when  the  body  is  situ- 
ated in  the  larynx,  to  remove  the  offending 
material  through  an  incision  should  extrac- 
tion per  vias  naturalis  be  impossible." 

"Tracheotomy  is  positively  indicated 
when  the  foreign  body  is  movable  in  the 
trachea." 

In  any  case  after  the  urgent  symptoms  have  subsided,  "operative 


462  FOREIGN  BODIES 

interference  is  the  special  form  of  treatment  most  rational  and  the 
form  of  operation  depends  upon  the  situation."  "If  the  extraction 
means  laceration,  it  is  justifiable  to  split  the  larynx  itself  or  a  sub- 
hyoid pharyngotomy  may  be  indicated." 

"The  expectant  treatment,  to  which  so  many  patients  formerly 
fell  victim,  is  to  be  condemned.  This  method  is  only  justifiable  in  a 
small  number  of  cases,  in  which  the  body  has  fallen  far  down  into  the 
bronchus  where  it  cannot  be  reached. 

' '  The  death  rate  shown  by  statistics  should  not  decide  the  question 
of  operation:  the  clinical  picture  of  the  particular  case  and  the  unfor- 
tunate cases  should  guide  the  surgeon.  Those  that  died  after  the 
operation  did  not  do  so  because  they  were  operated  upon,  but  because 
they  were  operated  upon  too  late.  In  an  individual  case  the  doctor 
can  never  count  upon  spontaneous  expulsion.  Every  hour  the  of- 
fending material  remains  in  situ  lessens  the  chances  more  and  more, 
while  operation  furnishes  conditions  most  favorable  for  its  removal. 
Opening  the  air  passages,  then,  is  the  most  rational  procedure  except 
for  the  cases  in  which  endolaryngeal  methods  can  be  used." 

RECTUM 

The  objects  which  have  been  removed  from  the  rectum  atone  time 
or  another,  cover  a  wide  range — bottles,  pieces  of  wood,  etc.,  pushed 
in  to  stop  a  diarrhea,  to  satisfy  a  perverted  sexual  impulse,  or  by  the 
insane. 

It  is  scarcely  necessary  to  indicate  all  the  instruments  and  artifices 
which  have  been  employed  in  their  extraction,  but  it  is  helpful,  as 
Lejars  points  out,  to  formulate  certain  general  rules  of  procedure. 

The  necessity  of  these  formulae  cannot  be  doubted  when  one  con- 
siders the  difiiculties  of  extraction,  often  considerable,  and  the  fre- 
quency with  which  the  rectum  is  lacerated  by  misguided  effort. 

Often  the  patient  does  not  admit  the  nature  of  his  difficulty,  con- 
sulting the  doctor  on  some  other  pretext,  such  as  constipation  or 
some  rectal  trouble  quite  different  from  the  real  condition.  In  the 
case  of  obscure  trouble  in  the  natural  orifices,  the  doctor  should  be  on 
his  guard.  If  the  nature  of  the  complaint  is  admitted,  proceed  to  a 
methodical  examination  and  endeavor  to  get  your  bearings. 


FOREIGN  BODIES   IN   THE   RECTUM 


463 


Introduce  a  finger,  which  has  been  well  oiled,  into  the  rectum. 
Sometimes  you  will  find  the  object  just  within  the  orifice,  of  such 
size  and  shape  that  it  can  be  readily  extracted  with  the  finger  or  with 
a  forceps  without  further  trouble,  but  you  cannot  count  too  much  on 
that. 

If  the  examination  shows  it  to  be  lodged  high  up  in  the  concavity 
of  the  sacrum,  impacted  and  perhaps  completely  filling  the  rectum, 
make  no  effort  at  extraction,  but  prepare  for  a  formal  operation. 


Fig.  355. — Foreign  body  in  the    rectum,     b.  Bottle;   &  Coccyx.      (Lejars.) 

Under  a  general  anesthetic,  put  the  patient  in  the  lithotomy  posi- 
tion with  the  thighs  well  flexed,  the  hips  elevated,  and  the  anal  re- 
gion in  a  good  light.  Dilate  the  anus  with  the  fingers  as  completely 
as  possible  and  then  determine  the  exact  "presentation"  of  the  body. 
Introduce  a  Sims'  speculum,  passing  it,  under  the  guidance  of  the 
finger,  beyond  the  coccyx,  and  then  retract  as  widely  as  possible. 
This  is  easily  done  in  the  young,  but  may  be  difi&cult  in  the  adult. 

When  the  coccyx  is  thus  sprung  back,  the  body  must  be  seized  and 
traction  made  in  the  axis  of  the  outlet  if  the  body  is  long  (a  bottle  for 


464  FOREIGN  BODIES 

example)  and  firmly  fixed  (Fig.  355).  The  fingers  or  forceps  may  be 
used.  If  you  are  dealing  with  glass,  the  blades  of  the  forceps  must 
be  covered  with  rubber  to  prevent  sHpping.  If  the  ends  of  the  for- 
eign body  are  pointed,  and  imbedded  in  the  rectal  wall  so  that  traction 
is  dangerous,  great  care  must  be  exercised.  In  some  cases  morcella- 
tion  will  be  possible. 

If  the  coccyx  cannot  be  retracted  and  serves  as  the  direct  impedi- 
ment, it  will  have  to  be  resected.  If  the  body  has  found  its  way  up 
into  the  left  iliac  region  into  the  sigmoid,  it  may  possibly  be  worked 
down  into  the  rectum  by  external  manipulation.  Finally,  in  such  a 
case,  laparotomy  and  opening  the  bowel  may  be  the  only  means  of 
relief. 

Combs,  of  Indianapolis,  reports  a  case  which  illustrates  the  prin- 
ciples of  treatment  involved  (J.  A.  M.  A.,  Oct.  23,  1909). 

After  a  drinking  bout  and  a  drunken  sleep  in  the  woods,  the  patient 
awoke  with  a  pain  in  his  rectum  and  found  it  impossible  to  empty  his 
bowel.  He  applied  to  a  physician  who  discovered  a  beer  glass  in  the 
rectum,  inserted  there  during  the  victim's  drunken  stupor  by  brutal 
comrades.  An  attempt  was  made  to  remove  the  glass  without  pre- 
liminary divulsion  of  the  sphincter.  During  traction  with  forceps 
the  glass  was  broken  and  the  attempt  failed. 

Some  hours  later  he  was  seen  at  the  hospital  by  Combs  who  found 
the  small  end  of  the  glass  resting  on  the  promontory,  and  the  large 
end  imbedded  in  the  hollow  of  the  sacrum  (Fig.  355),  its  broken 
edges  buried  in  the  soft  tissues.  By  reason  of  the  edema  and  swelling, 
divulsion  was  insufficient  for  removal,  and  consequently  the  con- 
tracted muscles  were  divided  in  the  middle  line  posteriorly,  when  the 
glass,  which  was  four  inches  long  and  seven  inches  in  circumference 
at  its  large  end,  was  readily  removed.  On  account  of  the  swelling 
and  evident  infection,  the  incision  was  left  to  heal  by  granulation,  and 
on  discharge  from  the  hospital  the  patient  had  a  perfect  control  of 
the  sphincter.  Combs  remarks  that  the  shape,  size,  and  nature  of 
the  foreign  body,  the  edema  and  swelhng,  and  the  degree  of  trauma- 
tism will  be  the  guiding  indications  for  the  course  to  pursue.  It 
would  certainly  seem  a  rare  instance  in  which  amputation  of  the 
coccyx  would  be  required.  Adequate  division  of  the  muscles  poste- 
riorly with  quick  removal  is  advised  in  lieu  of  prolonged  efforts  at  re- 


FOREIGN  BODIES   IN   THE   URETHRA  465 

moval  by  traction,  especially  of  an  object  with  cutting  edges  from 
which  fatal  wounds  may  result. 

THE  URETHRA 

A  piece  of  sound  may  be  broken  off  in  the  urethra.  Boys  or  the 
insane  may  lose  various  objects  in  the  urethra,  slate  pencils,  pipe 
stems,  pieces  of  watch  chain,  etc. 

As  a  rule,  the  accident  is  not  immediately  disastrous,  for  generally 
the  impediment  to  urination  is  not  complete.  The  object  should 
be  removed  as  soon  as  possible  and  with  as  Uttle  irritation  to  the 
urethra  as  possible. 


Fig.  356. — Urethral  forceps  of  Collin   U),  Leroy  d'EtioUes   (&),    and    Hunter    (c). 

It  is  necessary  merely  to  enumerate  some  of  the  methods  employed 
successfully  in  various  cases,  and  each  case  must  be  treated  on  its 
own  merits.  Often  the  body  may  be  easily  reached  and  extracted 
with  forceps  (Fig.  356).  In  certain  instances,  it  may  be  gradually 
worked  forward  by  external  pressure;  or  in  urination  the  meatus  may 
be  pinched  up  and  when  the  urethra  is  ballooned  out  by  the  pressure 
of  the  urine,  sudden  release  may  result  in  the  body  being  washed  out. 

In  case  the  body  is  in  the  deeper  part  of  the  urethra,  and  con- 
siderable manipulation  is  necessary,  pressure  should  be  applied  over 
the  urethra  on  the  bladder  side  of  the  foreign  body,  to  prevent  its 
being  pushed  deeper.  A  piece  of  hollow  sound  or  catheter  may  some- 
times be  removed  by  passing  a  smaller  sound  down  into  its  lumen; 
30 


466 


FOREIGN  BODIES 


or  the  urethral  speculum  or  a  larger  hollow  sound  may  be  passed 
down  to,  and  over  the  body,  w^hich  permits  its  more  ready  seizure  by 
a  forceps  passed  through  the  speculum. 

Dayat  shaped  a  lead  sheet  into  the  form  of  a  hollow  sound  and, 
passing  it  beyond  the  object  in  the  urethra,  closed  its  lower  end  by 
pressure  over  the  urethra  and  in  removing  the  lead  catheter  the 
foreign  body  came  out  with  it. 


Fig.  357. — Extracting  a  pin  from  the 
urethra  by  "version."  Protruding  the 
point  through  the  skin.      {Bryant.) 


Fig.  358. — Point  grasped  with  forceps. 
Its  direction  reversed  and  head  brought 
out  through  the  meatus.      (Bryant.) 


In  another  case,  a  stick  forced  into  the  urethra  could  not  be  with- 
drawn on  account  of  a  hook  on  its  lower  end,  but  after  being  split  into 
many  pieces,  its  extraction  was  accompHshed  piecemeal. 

In  the  case  of  a  pin  lost  in  the  urethra  head  downward,  its  point 
may  be  driven  through  the  skin  and  "version"  accompHshed  and  the 
head  brought  out  through  the  meatus  (Figs.  357,  358). 

In  other  cases  it  may  be  necessary  to  do  an  external  urethrotomy, 
and  finally  the  object  may  have  to  be  pushed  into  the  bladder  and 
removed  by  suprapubic  cystotomy. 


FOREIGN   BODIES    IN   THE  BLADDER  467 

Hazzard  describes  a  case  in  which  a  hat  pin  was  lodged  in  the  ure- 
thra, its  head  too  high  to  manipulate.  He  bent  the  penis  at  a  right 
angle  to  the  direction  of  the  pin  and  thus  thrust  its  point  through  the 
skin,  which  enabled  him  to  practise  version  (J.  A.  M.  A.,  May  29, 
1909). 

Hyde,  of  Kansas  City,  reports  a  shawl  pin  slipped,  head  first,  down 
the  urethra  and  into  the  bladder.  The  point  could  be  felt  at  the 
penoscrotal  angle.  An  incision  was  made  down  to  the  urethra,  the 
point  was  forced  through  the  urethral  wall  into  the  incision,  and  the 
pin  drawn  out  till  the  head  reached  the  urethral  floor;  it  was  then  re- 
versed and  delivered  through  the  meatus  without  opening  the  urethra. 
The  wound  was  closed  by  three  deeply  placed  silkworm-gut  sutures 
with  prompt  repair  (J.  A.  M.  A.,  March  13,  1909). 

Charlton  of  Indianapolis  operated  on  a  case  at  the  City  Hospital 
in  which  the  patient,  a  man  of  fifty  had  lost  the  bony  portion  of  a 
dog's  penis  in  his  urethra,  having  inserted  it  as  was  his  custom  to  re- 
lieve an  itching.  Painful  micturition  was  his  chief  symptom.  The 
bone  was  located  in  the  bladder,  a  cystotomy  performed,  the  foreign 
body  removed,  with  complete  recovery. 


CHAPTER  XXII 
BURNS,  SCALDS,  AND  FROSTBITE 

From  the  point  of  view  of  prognosis  and  treatment,  burns  are  of 
three  degrees: 

(i)  Transient  application  of  heat,  something  below  the  boiling- 
points,  produces  hyperemia. 

(2)  A  greater  degree  of  heat  or  a  longer  application  produces  a 
more  definite  vaso-motor  paralysis  and  there  is  exudation,  particularly 
into  the  Malpighian  layer,  and  the  epidermis  is  lifted  up  in  the  form 
of  blisters. 

(3)  The  albumen  of  the  tissues  and  fluids  is  coagulated.  This 
necrobiosis  may  be  superficial  or  it  may  involve  the  deep  structures 
as  well. 

Symptoms. — Even  in  slight  burns,  pain  is  always  a  prominent 
symptom.  In  the  severer  burns,  shock  is  always  present  in  some 
degree,  and  as  the  shock  disappears,  reaction  comes  on,  with  rise  of 
temperature,  and  the  symptoms  resolve  themselves  into  some  form 
of  internal  congestion,  or  systemic  intoxication,  characterized  by 
hemoglobinuria  or  albuminuria,  vomiting,  or  bloody  diarrhea.  After 
a  few  days  the  symptoms  may  be  those  of  septic  infection. 

The  cause  of  death  from  burns  faUs  into  four  groups: 

(a)  Shock.  This  may  be  rapidly  fatal,  sometimes  as  late  as  twenty- 
four  hours.  Death  may  be  due  to  cardiac  paralysis,  the  result  of 
over-heating  of  the  blood. 

(b)  Toxemia.  The  tox-albumens  resulting  from  the  chemical 
changes  in  the  tissues  find  their  way  into  the  circulation  and  over- 
whelm the  heart  and  kidneys,  usually  within  the  first  two  or  three 
days.  It  has  been  demonstrated  that  these  toxic  substances  are 
hemolytic  and  cytotoxic  for  the  parenchyma  cells  and  are  eliminated 
from  the  body  by  the  kidneys  and  intestinal  tract. 

(c)  Internal  congestion  and  inflammation,  involving  the  cerebral, 
thoracic,   or  abdominal  structures. 

468 


TREATMENT   OF  BURNS  469 

(d)  Septic  infection  or  its  sequelce.  This  may  be  fatal  after  the  first 
few  days  or  only  after  a  prolonged  struggle. 

Factors  Determining  the  Prognosis. — (a)  Area  and  depth  of  burn. 

(b)  Age  and  general  condition  of  patient. 

(c)  Region. 

(d)  Degree  of  infection. 

The  rules  for  determining  the  prognosis  can  be  formulated  only  in 
a  general  way  with  reference  to  these  various  factors,  and  yet  keep- 
ing them  in  mind,  a  quite  definite  forecast  may  often  be  made  in  a 
given  case. 

(a)  It  is  the  area  rather  than  the  depth  of  the  burn  which  deter- 
mines the  danger.  An  extensive  superficial  burn  is  more  dangerous 
than  a  hmited  but  deep  one.  It  appears  that  under  the  effect  of  heat 
muscular  tissue  generates  a  poison  much  less  toxic  than  that  from 
the  skin.  Mere  reddening  of  two-thirds  of  the  cutaneous  surface 
will  almost  inevitably  result  in  death,  while  destruction  of  one-third 
of  the  skin  will  probably  produce  the  same  result,  yet  most  burns  of 
the  first  and  second  class  commonly  met  in  practice  will  recover. 

(b)  The  age  and  general  condition  involve  the  question  of  the 
ability  to  rally  from  shock  and  to  resist  infection.  By  reason  of  their 
lack  of  resistance  to  these  forces,  the  young  or  the  aged  may  succumb 
to  even  slight  burns  of  the  third  degree. 

(c)  Burns  over  the  head  are  dangerous  for  the  reason  that  menin- 
gitis may  develop,  and  similarly  burns  of  the  thorax  and  abdomen  are 
likely  to  result  in  lesions  of  their  contained  viscera.  Burns  about  the 
face  are  often  accompanied  by  corresponding  injury  to  the  air  pas- 
sages by  inhalation  of  smoke  or  flames. 

(d)  The  most  important  factor,  however,  in  the  process  of  severe 
burns  is  injection.  Such  injuries,  in  fact,  are  infected  wounds.  The 
coagulated  albumens  of  the  destroyed  tissues  are  not  favorable  soil 
for  the  development  of  the  bacteria,  but  around  the  circumference  of 
the  burn  are  tissues  of  lowered  vitaHty  which  are  not  only  unable  to 
resist  the  encroaching  germ,  but,  more  than  that,\actually  nourish  it. 

The  serous  exudates  of  superficial  burns  aielikewise  culture 
media,  so  that  in  severe  burns  as  well  as  in  other  wodnds  it  may  be 
said  that  the  patient's  fate  lies  in  the  first  dressing. 

Treatment, — Slight  hums  of  the  first  degree  require  protection, 


1 


470  BURNS,    SCALDS,   AND   FROSTBITE 

which  may  be  furnished  by  vaseHne;  by  gauze  saturated  in  boracic 
acid  solution;  by  carron  oil;  by  dusting  powders  of  various  kinds, 
boracic  acid,  dermatol,  bicarbonate  of  soda,  flour. 

In  severe  hums  the  indications  are  to  combat  the  shock,  to  relieve 
the  pain,  and  to  prevent  infection.  In  the  matter  of  the  local  treat- 
ment of  these  conditions,  the  final  word  has  not  yet  been  spoken. 
The  most  divergent  opinions  appear  in  current  literature,  and  of  these 
various  lines  of  treatment  perhaps  none  are  wholly  bad,  certainly 
few  are  altogether  good. 

Begin,  then,  by  combating  shock  and  relieving  pain.  These  two 
conditions  are  usually  relieved  at  once  by  frequent  but  small  hypo- 
dermic doses  of  morphine,  supplemented  by  subcutaneous  or  venous 
injections  of  salt  solutions.  If  parts  beneath  the  clothing  are  in- 
volved, use  the  greatest  care  in  removing  so  that  the  skin  will  not  be 
removed  with  it. 

To  cut  the  clothing  is  safer  than  to  attempt  to  undress  the  patient. 
Always  remember  that  contact  with  the  clothing  may  be  the  chief 
source  of  infection. 

Now,  what  will  one  do  to  prevent  infection?  This  is  the  chief 
problem. 

If  the  burn  is  of  large  extent  and  depth  as  well  and  has  been  in 
contact  manifestly  with  sources  of  infection,  there  is  but  one  thing 
to  do  if  the  aseptic  method  is  to  be  employed.  Anesthetize  the 
patient  after  the  shock  has  passed  and  proceed  to  sterilize  the  parts. 
Scrub  the  uninjured  skin  around  the  wound  with  soap  and  water  and 
then  alcohol  and  bichloride.  Next  proceed  to  irrigate  the  burned 
area  with  normal  salt  solution,  in  the  meantime  carefully  rubbing 
with  sterile  gauze,  to  the  end  that  every  bit  of  foreign  matter  may 
be  removed.  In  those  parts  that  are  merely  blistered,  the  blebs 
are  to  be  punctured  and  the  serum  washed  away.  It  may  be  advis- 
able, even,  for  the  sake  of  thorough  disinfection,  to  make  no  effort 
to  spare  the  cuticle  of  the  blisters  in  rubbing  with  the  sterile  gauze. 

Not  hurriedly,  but  patiently  complete  this  cleansing.  It  will  prob- 
ably require  from  one-half  to  three-quarters  of  an  hour,  but  it  is 
time  well  spent.     You  have  now  to  deal  with  an  aseptic  wound. 

Next  cover  the  area  with  plain  sterilized  or  borated  gauze  and 
over  this  apply  absorbent  cotton  and  bandage  snugly. 


OINTMENT   OF    RECLUS 


471 


If  much  CLilicle  has  been  removed,  cover  with  sterile  vasehne 
before  applying  the  sterile  gauze. 

The  aid  of  a  splint  may  be  required  to  prevent  deformity.  If 
no  fever  arises  the  dressing  need  not  be  changed  for  eight  or  ten 
days. 

It  may  not  be  practical  to  institute  the  thorough  disinfection  which 
anesthesia  alone  permits,  but  one  can  at  least  cleanse  the  adjacent 
area  as  before  described.  Prick  the  blisters  and  irrigate  the  burnt 
area  with  normal  salt  solution,  but  in  this  case  sterilization  is  not  so 
much  a  certainty. 

Therefore,  you  must  employ  an  antiseptic  dressing.  Whatever 
dressing  you  select  should  have  these  properties  at  least;  it  should  be 
antiseptic,  analgesic,  and  keratogenic.  A  number  of  substances 
possess  these  properties  in  various  degrees  and  are  otherwise  more 
or  less  unobjectionable. 

Picric  Acid. — This  is  employed  in  solutions  of  i  or  2  per  cent.  A 
good  solution  is  made  by  dissolving  ij^  drams  in  3  ounces  of 
alcohol  and  adding  some  of  this  solution  to  two  parts  of  water. 
After  cleansing  the  surface  apply  strips  of  sterile  gauze,  soaked  in 
the  solution,  cover  with  absorbent  cotton  and  bandage.  Change 
the  dressing  in  three  to  four  days,  soaking  it  loose  with  the  same 
solution.  Picric  acid  stains  are  removed  by  an  alkaline  sulphide 
followed  by  washing  with  soap  and  water  or  by  a  paste  of  manga- 
nese carbonate  and  water. 

Turpentine. — 'This  is  an  excellent  domestic  remedy,  antiseptic  and 
analgesic,  but  only  to  be  employed  in  slight  burns  of  the  first  degree. 
Cover  the  area  with  absorbent  cotton  and  saturate  with  the  turpen- 
tine, and  bandage. 

Aristol. — This,  too,  renders  excellent  service.  Use  as  an  ointment 
mixed  with  sterile  vaseline  or  zinc  ointment  in  the  proportion  of  8  to 
10  grains  to  the  ounce  and  apply  spread  on  sterile  gauze. 

The  Ointment  of  Rectus. — This,  perhaps  better  than  any  other 
ointment,  meets  all  the  indications.  It  is  applied  in  a  thin  layer 
directly  to  the  surface  or  spread  on  sterile  gauze  and  the  dressing 
completed  with  cotton  and  bandage.  Here  is  the  formula  of  the 
ointment  as  modified  by  the  author  and  prepared  by  the  Pitman, 
Myers  Co.,  and  which  should  be  ready  for  instant  use: 


472  BURNS,    SCALDS,   AND  FROSTBITE 

I^ — Hydrarg.  Chlor.  Corros.,  i  part. 

Acid  Carbol.,  30  parts, 

Aristol,  30  " 

Acid  Boric,  90  " 

Salol,  go  " 

AntipjTine,  150  " 

Petrolatum,  576  " 

Carron  Oil. — This  is  an  old  and  useful  remedy,  but,  as  ordinarily 
used,  unqualifiedly  to  be  condemned.  It  favors  suppuration  because 
it  is  in  nowase  antiseptic  and  perhaps  may — indeed  often  does — carry 
infection.  If  the  oil  is  sterilized  and  then  apphed  to  the  surface 
which  has  been  made  as  clean  as  possible,  it  is  an  efficient 
dressing. 

Granger,  of  Rochester,  Minn.,  uses  equal  parts  of  lanolin  and  zinc 
ointment  spread  thickly  on  gauze,  covering  the  ointment  with  the 
waxed  paper  sold  by  instrument  dealers,  and  applying  the  dressing 
with  the  paper  next  to  the  burned  surface.  The  dressing  is  next 
covered  -^ith  a  thin  layer  of  cotton.  He  claims  that  it  is  soothing 
and  easily  removed. 

The  frequency  with  which  any  dressing  must  be  changed  will 
depend  on  the  pain  or  infection.  If  the  secretions  are  excessive  and, 
by  drying  and  stiffening  the  dressing,  aggravate  the  pain,  the  dress- 
ings must  be  frequently  changed. 

If  there  is  infection,  the  rise  of  temperature  will  be  the  index.  The 
same  care  must  be  exercised  in  changing  the  dressings  as  in  treating 
any  other  wound. 

BURNS  OF  THE  MOUTH 

Burns  of  the  inonth  and  air  passages  are  not  infrequent.  These 
may  be  the  result  of  taking  hot  substances  into  the  mouth  or  the 
inhalation  of  hot  gases  in  explosions.  Pain  and  difficulty  in  swallow- 
ing are  the  most  frequent  symptoms.  In  addition  there  may  be 
edema  of  the  glottis  or  finally  acute  bronchitis  may  develop.  Cold 
water  and  bits  of  ice  give  the  most  rehef.  The  edema  of  the  glottis 
may  require  tracheotomy.  The  various  forms  of  inflammation,  such 
as  bronchitis  or  pneumonia,  must  be  treated  on  general  principles. 


SYMPTOMS  OF  ELECTRICAL  SHOCKS  473 

ELECTRICAL  BURNS  AND  SHOCKS 

Electrical  burns  are  painful  out  of  all  proportion  to  the  size  of  the 
lesion  and  require  two  or  three  times  as  long  as  the  ordinary  burn  for 
repair. 

Begin  the  treatment  with  hypodermics  of  morphia  and  strychnia 
(1/30).  Cleanse  the  wound  by  the  ordinary  surgical  methods  and 
dress  with  sterile  gauze,  cotton,  and  bandage. 

The  resuscitation  of  persons  shocked  by  electricity  is  necessitated 
much  more  often  than  formerly  by  reason  of  the  widespread  use  of 
the  electric  current.  Spitzka  has  lately  outlined  the  course  to  pursue 
in  the  treatment  of  such  cases.  He  remarks,  in  the  first  place,  that 
one  cannot  safely  predict  exactly  what  will  happen  in  any  case  of 
shock  by  electricity,  for  many  factors  modify  the  action  of  the  cur- 
rent: its  nature,  tension,  intensity;  the  resistance  and  susceptibility 
of  the  individual;  the  duration,  location,  and  area  of  contact. 
Broadly  stated,  the  effect  is  the  more  severe,  the  greater  the  voltage, 
the  greater  the  amperage,  the  longer  the  period  of  contact,  the  greater 
the  area  of  contact,  and  the  longer  the  path  of  the  current  through 
the  body. 

Death  by  electrical  contact  would  appear  to  be  due  to  heart  paraly- 
sis or  to  asphyxia,  or  a  combination  of  both.  In  certain  cases  there 
is  no  paralysis  of  the  heart,  but  only  respiratory  failure. 

The  symptoms  of  electrical  shock  in  cases  which  are  not  immedi- 
ately fatal,  vary  greatly  in  form  and  degree. 

I.  Local  signs: 

(a)  Burns  and  superficial  necroses. 

(b)  Puncture  and  rupture  of  tissues. 

(c)  Hemorrhages. 

(d)  Edema  and  erythemas. 

II.  General  effects: 

(a)  Loss  of  consciousness. 

(b)  Paralysis  and  spasms  of  muscles. 

(c)  Disturbances  of  respiration  and  circulation. 

(d)  High  temperature. 


474  BURNS,    SCALDS,   AND   FROSTBITE 

Later  there  may  develop  disturbances  of  the  bowels,  kidneys, 
special  sense  organs,  the  central  and  peripheral  nervous  system. 

The  prognosis  is  good  only  in  cases  where  there  is  some  heart 
action  and  respiration  and  where  treatment  can  be  promptly  applied. 

Treatment. — -If  the  stricken  man  is  not  out  of  the  circuit,  some  cau- 
tion must  be  exercised  in  accomphshing  his  relief.  The  rescuer 
should  have  on  rubber  gloves  or  have  his  hands  wrapped  in  thick 
dry,  woolen  material,  to  avoid  shock  from  handling  the  victim.  He 
may  be  freed  by  pulling  at  his  clothing  or  using  sticks  of  wood.  If 
it  is  necessary  to  cut  a  wire,  the  nippers  must  have  insulated  handles 
and  the  eyes  should  be  protected  from  the  blinding  flash. 

Once  freed,  the  patient  should  be  laid  with  head  elevated  and  arti- 
ficial respiration  at  once  begun.  This  is  more  effectively  done  by 
compressing  the  chest  with  the  hands  applied  flat  against  the  sides 
of  the  lower  part  of  the  thorax.  The  tongue  must  be  drawn  forward 
so  as  not  to  obstruct  the  larynx.  Massage  over  the  heart  and 
faradism  help  to  stimulate  its  action.  Arterial  infusion  of  adrenalin 
has  been  proven  by  Crile  and  Dolly  to  have  a  direct  effect. 

Other  methods  which  have  been  suggested  are  lumbar  puncture, 
venesection,  and  the  high-tension  shock  of  short  duration  (Jour. 
Med.  Soc.  New  Jersey,  Jan.,  1909). 

FREEZING 

The  effects  of  very  low  temperature  on  the  tissues  are  practically 
the  same  as  those  of  heat.  The  ultimate  effect  is  death  of  the  tissues 
or  gangrene. 

The  treatment  of  patients  overcome  by  cold  must  be  circumspect. 
The  main  point  is  to  go  slow  in  warming  the  parts.  The  patient 
should  never  be  brought  directly  from  outdoors  into  a  warm  room. 
Sonnenburg  advises  that  a  cold  bath,  the  temperature  of  the  cold 
room,  be  used,  and  the  temperature  gradually  raised  until  in  two 
or  three  hours  it  reaches  80°  F.  Where  life  seems  extinct,  artificial 
respiration  should  be  practised,  and  sometimes  the  circulation  may 
thus  be  re-estabUshed.  Subsequently  hot  rectal  enemata  of  whiskey 
or  coffee  may  be  employed.  The  limbs  and  other  frozen  parts 
should  be  covered  w4th  moist  compresses  for  the  first  forty-eight 


FREEZING  475 

hours  and  then  dusted  with  boracic  acid  and  encased  in  a  thin  layer 
of  wool. 

If  the  trouble  is  only  local — a.  frozen  ear  or  foot — -begin  by  rubbing 
the  part  with  snow  or  ice  and  then  with  cold  water  and  finally  apply 
cold  compresses,  gradually  raising  their  temperature  until  the  circu- 
lation is  restored.  Subsequently  cooling  lotions  may  be  employed 
to  allay  the  inflammation. 

The  frostbite  of  the  feet  so  common  in  the  trench  fighting  of  the 
European  war,  resulting  often  in  gangrene  is  not  due  so  much  to 
the  cold  as  to  interference  with  the  circulation,  the  result  of  wearing 
soggy  socks  and  shoes  unchanged,  perhaps,  for  days. 


PART  II 

CHAPTER  I 
TRACHEOTOMY,  LARYNGOTOMY,  ESOPHAGOTOMY 

Tracheotomy  is  often  performed  in  general  practice  as  an  opera- 
tion of  the  greatest  urgency,  and  one  should  be  prepared  to  do  it 
anywhere,  at  any  time,  and,  if  necessary,  with  a  pen-knife.  Yet  it  is 
not  so  simple  a  procedure  as  one  might  infer.  To  do  it  properly  and 
quickly,  requires  coolness,  knowledge,  and 
method.  It  is  the  measure  of  reUef  indicated 
in  every  case  of  laryngeal  asphyxia,  whether 
due  to  spasm  of  the  larynx,  edema  following 
burns,  injuries,  or  disease  such  as  diphtheria 
or  cancer;  or  to  the  presence  of  foreign  bodies. 
In  the  case  of  diphtheria,  intubation  is  always 
preferable  to  tracheotomy,  but  the  necessary 
appliances  may  be  lacking.  The  essential 
equipment  for  tracheotomy  is  a  sharp  pointed 
scalpel  and  a  tracheotomy  tube,  and  to  these  Fig.  359.— Tracheotomy 
as  mere  conveniences,  may  be  added  scissors, 
artery  and  dissecting  forceps,  tenacula,  mouth-gag,  and  tongue 
forceps. 

The  tracheotomy  tube  (Fig.  359)  should  be  of  simple  construction, 
easy  to  introduce,  and  as  large  as  the  diameter  of  the  trachea  will 
admit.  Treves  furnishes  the  following  table  relative  to  the  age  of 
the  patient  and  the  diameter  of  the  tube: 

AGE  DIAMETER  OF  THE   TUBE 

Under  18  months,  4  mm. 

ii.^  to  2  years,  5  mm. 

2  to  4  years,  6  mm. 

4  to  8  years,  8  mm. 

8  to  12  years,  10  mm. 

12  to  15  years,  12  mm. 

Adults,  12  to  15  mm. 

477 


478 


TRACHEOTOMY,   LARYNGOTOMY,    ESOPHAGOTOMY 


Even'  practitioner  should  have  tubes  of  various  sizes  in  his  "arse- 
nal;'' Senn  recommends  Trousseau's,  while  Lejars  prefers  those  of 
Krishaber,  because  less  Hkely  to  become  occluded. 

Anesthesia  is  often  unnecessary,  owdng  to  the  condition  of  the  pa- 
tient. Otherwise  a  few  whiffs  of  chloroform  should  suffice.  It  need 
scarcely  be  said  that  under  these  circumstances,  free  use  of  the 
anesthetic  will  only  hasten  the  fatality. 

The  preparation  of  the  field  can  be  hastily  but  sufficiently  done  by 
painting  with  iodine. 


Fig.  360. — Locating  the  cricoid  cartilage.     (Veau.) 


The  little  patient's  arms  should  be  pinioned  to  its  sides  with  a  towel 
or  sheet,  it  should  be  placed  on  its  back  with  a  cushion  under  its 
shoulders  to  drop  the  head  backward  and  bring  the  trachea  into 
bolder  relief. 

Operation. — Stand  at  the  right  side  of  the  patient;  locate  the  hyoid 
bone,  the  thyroid  prominence,  the  cricoid  cartilage,  and  the  sternal 
notch;  and  steady  the  trachea,  holding  the  cricoid  between  the  middle 
finger  and  the  thumb  of  the  left  hand,  while  the  index  finger  locates 
the  middle  line  (Fig.  360). 

It  is  along  the  middle  line  that  one  must  incise,  and  the  aim  is  to 
divide  the  upper  rings  of  the  trachea  and  to  avoid  the  thyroid  isthmus 
(Fig.  361). 


TRACHEOTOMY 


479 


Make  the  incision  from  the  index  linger  downward  exactly  in  the 
middle  line  for  2  inches  (Fig.  362).  Incise  rapidly  with  a  single 
sweep  of  the  knife.  The  left  index  linger  in  the  upper  angle  of  the 
wound  hooks  up  the  cricoid  and  still  locates  the  middle  line.  Pay 
no  attention  to  the  bleeding,  and  without  hesitation  push  the  point 
of  the  bistoury  through  the  upper  ring  and  cut  downward  through 
the  second  and  third  if  necessary.  The  air  hisses  through  the 
opening.     It  is  a  moment  of  confusion,  but  one  must  keep  cool. 

Insert  the  tube.  Without  changing  its  position, 
the  left  index  finger  presses  the  tracheal  wound 
open  and  the  right  hand  introduces  the  tube. 
It  is  held  horizontally  at  first,  until  the  point  is 
well  in  the  trachea,  and  then  is  carried  upward 
in  a  curve  until  its  beak  corresponds  to  the 
lumen  of  the  trachea  (Fig.  363).  The  patient's 
gasps  expel  blood  and  perhaps  false  membrane, 
which  the  attendants  must  avoid  inhaling.  The 
tapes  attached  to  the  tube  are  fastened  behind 
the  neck.  Apply  artificial  respiration  if  the 
patient's  condition  is  not  satisfactory.    Let  the 

.-,  -i  .   ^  ..-I        Fig.    361.— Trache- 

air  pass  through  a  warm,  moist  compress  until  otomy.    Dotted  lines 
the  temperature  of  the  room  can  be  regulated,  represent  the  thyroid 

As  Veau  points  out,  the  operation  may  fail  for 
several  reasons,  all  within  the  control  of  the  operator.  The  most 
frequent  cause  of  failure  is  faulty  introduction  of  the  tube;  it  does 
not  enter  the  tracheal  canal,  but  is  pushed  down  between  the 
mucous  membrane  and  the  tracheal  wall.  These  structures  are 
loosely  connected.  The  error  is  to  be  recognized  by  the  absence 
of  the  characteristic  sound  of  escaping  air. 

The  orifice  is  to  be  inspected,  and,  if  too  small,  enlarged,  before 
trying  the  second  time  to  introduce  the  tube. 

Again,  too  much  force  in  making  the  incision  may  result  in  wound- 
ing the  posterior  wall  of  the  trachea.  Excited  operators  have  split 
the  trachea  its  entire  length,  or  wounded  the  vessels  of  the  neck. 
There  need  be  but  little  hemorrhage  in  the  operation,  if  one  but  keeps 
in  the  middle  line;  and,  as  Senn  says,  that  is  the  secret  of  success  in 
performing  the  operation  quickly  and  safely. 


48o 


TRACHEOTOMY,    LARYNGOTOMY,    ESOPHAGOTOMY 


Fig.  362. — Tracheotomy.    Incision.     (Veau.) 


Fig.  363. — Introducing  the  tracheotomy  tube.    {Veau.) 


TRACHEOTOMY  FOR   FOREIGN  BODIES  48 1 

The  operation  may  be  varied  somewhat,  depending,  of  course, 
upon  the  conditions.  The  cricoid  may  be  divided  if  necessary.  In 
other  cases,  before  cutting  downward  it  may  be  necessary  to  draw 
downward  the  isthmus  of  the  thyroid  gland  before  enlarging  the 
opening. 

In  any  case  where  time  does  not  press,  as  when  the  tracheotomy  is 
done  preliminary  to  some  other  operation,  the  various  steps  may  be 
carried  out  with  more  detail,  the  incision  made  by  layers,  vessels 
clamped,  and  the  rings  exposed,  steadied  with  hoods  and  incised. 

The  tracheotomy  may  be  done  below  the  isthmus  of  the  thyroid, 
but  the  higher  operation  is  much  the  easier  anatomically,  although 
the  principle  is  the  same. 

Tracheotomy  for  foreign  bodies  differs  in  some  respects  from  the 
ordinary  technic.  Westmoreland,  of  Atlanta,  who  has  had  a  large 
experience  with  this  class  of  cases  has  recently  emphasized  some  of 
these  points  (Amer.  Jour,  of  Surg.,  Nov.,  1909). 

The  incision  should  vary  in  length  depending  upon  the  size  and 
character  of  the  foreign  body.  If  the  opening  is  sufficiently  large 
the  foreign  body  is  easily  expelled  by  the  respiratory  effort;  usually 
the  opening  is  made  too  small  and  the  trachea  is  injured  by  the  forci- 
ble extraction  of  the  body.  In  the  young  the  thyroid  isthmus  is 
usually  in  the  way  and  should  be  divided  between  forceps  and  ligated. 
Even  the  thymus  gland  may  intrude  and  is  to  be  depressed  with  a 
narrow  retractor.  A  tenaculum  should  not  be  employed  lest  it 
excite  a  troublesome  bleeding. 

The  incision  in  the  trachea  itself  begins  at  the  first  ring.  If 
asphyxia  should  occur  in  the  course  of  the  operation,  the  result  of 
fixation  of  the  object  in  the  glottis,  the  operation  should  be  rapidly 
finished,  a  tube  or  catheter  passed  into  the  trachea  and  the  lung  in- 
flated by  blowing  through  the  tube — -a  great  help  in  artificial  respira- 
tion which  soon  resuscitates  the  asphyxiated  child. 

Tracheotomy  tubes  are  not  to  be  used.  Once  the  trachea  is  opened 
the  body  may  be  coughed  out  which  a  tube  would  prevent.  The 
wound  may  be  held  open  if  necessary  by  silk  threads  passed  through 
its  edges. 

//  the  foreign  body  is  expelled  the  trachea  is  to  be  sutured  at  once, 
employing  a  mattress  suture  of  silk  which  is  not  to  pass  through  the 
31 


482  TRACHEOTOMY,    LARYNGOTOMY,   ESOPHAGOTOMY 

mucous  membrane.  Whether  the  tracheal  wound  i^  made  air-tight 
or  not  is  to  be  tested  by  filling  the  wound  with  normal  salt  solution 
and  obstructing  the  nose  and  mouth  which  will  force  some  bubbles 
through  if  not  tight.  The  fascia,  muscles  and  isthmus,  and  finally 
the  skin  are  repaired.  The  dressing  is  held  in  place  by  adhesive 
strips. 

//  inflammation  exists,  even  though  the  body  is  expelled,  do  no 
suturing;  cover  the  wound  loosely  with  bichloride  gauze  to  keep  out 
cold  air  and  to  absorb  the  discharges.  Change  the  dressing  fre- 
quently. 

//  the  foreign  body  is  not  expelled  the  protective  dressing  is  to  be 
applied  which  will  not  prevent  the  escape  of  the  object  if  it  should 
be  coughed  up  later,  and  under  this  treatment  the  inflammation  will 
probably  rapidly  subside. 

After-treatment. — The  success  of  tracheotomy  rests  largely  on  the 
care  with  which  the  after-treatment  is  conducted.  There  is  no 
operation,  perhaps,  in  which  care  and  skill  are  better  rewarded  and 
negligence  and  ignorance  more  severly  punished.  If  the  temperature 
of  the  room  cannot  be  kept  at  close  to  65°,  the  tube  should  be  kept 
covered  with  a  warm,  moist  compress.  The  wound  must  be  kept 
clean.  For  the  first  few  days,  the  inner  tube  must  be  removed  and 
cleansed  several  times  daily.  This  should  be  done  rapidly,  and  the 
tube  disinfected  and  oiled  before  being  reintroduced. 

Morse  (Post-operative  Treatment,  page  174)  says,  unless  the 
cause  of  obstruction  is  a  permanent  one,  it  is  often  advisable  to 
remove  the  tube  after  twenty-four  to  forty-eight  hours;  but  the 
patient  should  be  allowed  to  try  breathing  through  the  mouth  before 
removing  the  tube,  testing  his  capacity  by  stopping  the  cannula. 
In  any  event,  he  should  be  gradually  accustomed  to  breathing 
through  the  mouth  by  plugging  the  canula. 

Morse  advised  that  soup,  milk,  or  broth  should  be  given  at  first, 
if  necessary  through  a  nasal  or  esophageal  tube,  although  this  is  not 
often  required.  Difficulty  in  swallowing  is  likely  to  occur  on  the 
third  or  fourth  day,  but  encouragement  will  enable  the  patient  to 
overcome  this.     Nutrient  enemas  are  rarely  necessary. 

Link,  of  Indianapolis,  relates  an  experience  (Medical  Record, 
March  2,  1907)  which  illustrates  at  once  the  value  of  the  operation, 


TRACHEOTOMY  FOR  LARYNGEAL  EDEMA  483 

the  improvisation  of  instruments  to  meet  an  emergency,  and  one  of 
the  rarer  forms  of  suffocating  edema. 

At  midnight  he  was  called  to  see  a  patient  said  to  be  choking  to 
death  and  whom  he  supposed  had  an  attack  of  asthma.  He  found 
the  patient,  a  man  weighing  250  pounds,  cyanosed  and  laboring 
for  breath.  One  hour  previously,  it  seems,  his  throat  had  been 
lanced  for  the  eleventh  time  in  the  course  of  a  ten  days'  attack  of 
tonsillitis. 

A  hurried  examination  found  the  pharynx  too  tightly  swollen  to 
pass  a  finger.  How  much  laryngeal  edema  there  might  be  could 
only  be  guessed.  Thinking  to  intubate  past  the  swollen  pharynx, 
Link  used  the  only  thing  available,  the  vaginal  tip  from  a  hard- 
rubber  syringe,  bent  at  nearly  a  right  angle.  The  attempt  failed. 
While  preparing  for  a  local  anesthesia  to  do  a  tracheotomy,  the 
patient's  neck  was  surrounded  with  iced  cloths,  but  this  seemed 
to  aggravate  the  asphyxia;  the  patient  became  unconscious  and 
ceased  to  breathe. 

The  anesthesia  was  no  longer  necessary.  All  had  fled  but  one 
woman,  and  while  she  held  the  patient's  head,  the  doctor  did  a  low 
tracheotomy. 

He  says,  kneeling  in  front  of  the  patient,  who  was  in  a  sitting  pos- 
ture, he  incised  the  skin  and  deep  fascia  in  the  median  line  2  inches 
above  the  sternal  notch,  working  with  his  finger  down  to  the  bron- 
chial rings.  With  the  finger  as  a  guide,  the  knife  was  introduced,  the 
trachea  stabbed  and  cut  slightly  upward.  A  closed  hemostat  was 
then  introduced  and  opened.  Very  little  blood  was  lost.  A  female 
silver  catheter  from  his  pocket  case  was  introduced  and  held  in  place 
by  the  assistant,  while  the  doctor  performed  artificial  respiration. 

The  patient  soon  began  to  breathe,  but  his  convulsive  movements 
threatened  the  loss  of  the  small  tube  in  the  throat.  The  hard-rubber 
vaginal  syringe  tip  was  brought  into  use  again,  whittled  and  inserted. 
The  elbow  shape  fitted  perfectly.  In  half  an  hour  the  patient  asked 
to  be  put  to  bed,  and  breathing  entirely  through  the  tube,  slept  the 
first  sleep  for  several  nights. 

The  edema  declined  as  fast  as  it  had  arisen,  and,  within  a  few 
hours,  the  patient  could  breathe  through  the  mouth  when  the  tube 
was  closed,  and  recovery  was  uneventful. 


484 


TRACHEOTOMY,   LARYNGOTOMY,    ESOPHAGOTOMY 


LARYNGOTOMY 

As  an  emergency  operation,  this  is  most  frequently  done  in  an  adult 
for  cancer,  but  one  need  not  wait  until  the  patient  is  asphyxiated  for 
there  is  nothing  gained  thereby.  Therefore  one  may  operate  deliber- 
ately, for  there  is  not  the  extreme  urgency  as  with  the  infant. 

Local  anesthesia  may  be  sufficient.  Define  as  before  the  inferior 
border  of  the  thyroid  cartilage  and  the  upper  border  of  the  cricoid, 
between  which  is  the  crico-thyroid  membrane  which  is  to  be  incised 
(Fig.  364).  In  the  middle  line  over  the  space, 
make  a  vertical  incision  an  inch  long.  Catch 
the  bleeding  points  and  retract  the  lips  of  the 
wound.  Carefully  incise  the  fascia  until  these 
cartilages  are  exposed.  Now  incise  the  crico- 
thyroid membrane  transversely  and  open  into 
the  larynx  (Fig.  365). 

Introduce  the  tube  as  in  tracheotomy.  Re- 
move and  cleanse  the  inner  tube  on  the  first  two 
days  and  the  large  tube  on  the  third  day. 

Of  course,  if  the  operation  is  for  cancer,  it  is 
merely  palliative  and  the  patient  will  continue 
slowly  to  die.  If  the  operation  is  for  edema  of 
the  larynx,  the  cause  must  be  treated  and  the 
proper  time  finally  to  withdraw  the  tube  deter- 
mined by  the  conditions.  If  the  operation  is  for  a  foreign  body,  the 
wound  may  be  sutured  at  once. 


Fig.  364- — Laryn- 
gotomy.  Incision  of 
crico-thyroid  mem- 
brane.    {Veau.) 


ESOPHAGOTOMY  (Cervical  Region) 

This  is  an  operation  only  exceptionally  of  value  fort  he  esopha- 
goscope  will  usually  enable  the  foreign  body  to  be  removed  without 
operation  even  after  the  ordinary  maneuvers  have  failed  (see  Foreign 
Bodies).  Nevertheless  in  the  case  of  irregular  bodies  fixed  in  the 
lower  cervical  region  it  is  preferable  to  open  the  esophagus  rather 
than  lacerate  the  mucosa  in  dragging  the  object  out.  A  skiagraph 
will  help  to  locate  the  body  definitely  preHminary  to  operation. 


ESOPHAGOTOMY 


485 


Position. — Place  the  patient  on  his  back  with  shoulders  elevated 
and  the  neck  resting  on  a  sand-bag  with  head  turned  to  the  right. 

Incision. — Begin  opposite  the  upper  border  of  the  thyroid  cartilage 
and  continue  downward  along  the  anterior  border  of  the  left  sterno- 
mastoid  for  3  or  4  inches,  incising  the  skin,  superficial  fascia,  and  plat- 
ysma.  Ligate  the  veins  and^draw  the  sterno-mastoid  forward  and 
the  depressors  of  the  hyoid  downward  (Fig.  366).  The  wound  is  thus 
enlarged  and  at  the  bottom  is  the  layer  of  cervical  fascia  connecting 


Fig.  365. — ^Laryngotomy.    Incision  of  the  crico-thyroid  membrane.    (Veau.) 
It  is  better  to  cut  transversely  in  order  to  avoid  the  crico-thyroid  artery. 


the  thyroid  gland  and  the  sheath  of  the  large  vessels.  Incise  it  and 
again  enlarge  the  wound  by  drawing  forward  the  thyroid  gland, 
trachea,  and  larynx,  and  backward,  the  great  vessels  in  their  sheaths. 

At  this  stage,  in  the  bottom  of  the  wound  are  the  inferior  thyroid, 
which  must  be  ligated,  and  the  recurrent  laryngeal  nerve,  which 
should  be  drawn  forward. 

The  esophagus  now  appears  as  a  red  tube.  To  steady  the  esoph- 
agus and  define  its  walls,  an  esophageal  bougie  may  be  inserted. 
The  wall  of  the  esophagus  is  raised  with  mouse-tooth  forceps  (Fig. 


486 


TRACHEOTOMY,    LARYNGOTOMY,    ESOPHAGOTOMY 


367)  and  incised  along  its  lateral  wall.  A  suture  is  passed  through 
each  lip  of  the  incision,  that  they  may  be  readily  retracted  while  the 
foreign  body  is  located  and  removed,  not  always  the  easiest  part 
of  the  task. 

The  wound  of  the  esophagus  is  repaired  with  sutures  of  catgut 
and  the  rest  of  the  wound  lightly  packed  with  gauze  until  all  danger 
of  infection  is  passed. 


■Sterno-thur. 
^St.-hyo'id. 
.  Otno-hyonl 
■  Sterno-masli. 


Fig.  366. — Esophagotomy:  exposing    the    infra-hyoid    group    of    muscles.     (Lenormaut.) 


As  Bryant  says,  ordinarily  the  operation  of  cervical  esophagotomy 
is  not  a  perplexing  procedure,  but  when  the  neck  is  short  and  fat, 
the  vessels  and  thyroid  gland  enlarged,  the  detection  and  removal 
of  the  foreign  body  difficult,  or  the  patient  exhausted,  the  operation 
often  taxes  the  patience  and  fortitude  of  the  surgeon. 

After-treatment. — The  patient  must  be  kept  in  bed  with  shoulders 


ESOPHAGOTOMY 


487 


raised.     Nourishment  should  be  given  at  first  by  cncmata,  and  later, 
if  necessary,  by  the  esophageal  tube. 

Nassau  reports  a  case  illustrating  the  subject.  A  child  swallowed 
a  five-cent  piece  and  thereafter  could  take  only  liquid  foods.  "X- 
ray"  examination  showed  the  coin  lodged  at 
the  level  of  the  suprasternal  notch  or  just 
above. 

Removal  was  attempted  with  forceps  but 
without  success,  although  the  coin  could  be 
felt.  An  esophagotomy  was  done.  The  opera- 
tion was  completed  in  fourteen  minutes.  No 
vessels  require  ligation.  The  esophagus  was 
not  sutured  and  the  superficial  wound  was 
closed  with  drainage.  There  was  no  leakage 
and  the  child  made  an  uneventful  recovery. 
Nassau  does  not  regard  esophagotomy  as  a 
serious  operation,  but  believes  it  should  not 
be  considered  until  efforts  at  extraction  have  failed. 


Fig.  367. — Esophagot- 
omy. Final  incision. 
(Bryant.) 


CHAPTER  II 

URGENT  THORACOTOMY.     REPAIR  OF  INJURY  TO  THE 

LUNGS.    REPAIR  OF  INJURY  TO  THE  PERICARDIUM ; 

OF  INJURY  TO  THE  HEART,    PUNCTURE  OF 

THE  PERICARDIUM 

As  has  been  indicated  elsewhere  (see  Injuries  of  the  Thorax), 
urgent  intervention  for  injuries  of  the  thorax  is  a  form  of  operative 
procedure  at  this  present  time  with  but  a  Hmited  field.  Whatever 
may  be  the  apparent  gravity  of  the  case,  it  is  far  from  being  the  rule 
to  operate,  for  such  operations  require  trained  assistants,  a  special 
equipment,  and  a  superior  surgical  skill.  Of  necessity,  then,  in 
general  practice,  the  treatment  must,  generally  speaking,  be  con- 
servative: that  is  to  say,  cleansing  of  the  external  wound  with  en- 
largement and  trimming  up  if  necessary,  reunion  and  aseptic  oc- 
clusion, firm  bandaging  of  the  thorax,  and  an  absolute  quiet  in  bed. 
These  measures  along  with  stimulation  with  cafTein  and  camphor- 
ated oil  and  normal  salt  solution,  represent  the  elements  of  treat- 
ment which  are  within  the  scope  of  all. 

But  there  are  cases  so  manifestly  fatal  without  operation  that,  as 
Lejars  says,  one  cannot  evade  the  question,  "operate  or  let  die?" 

Grave  rupture  of  the  lung  indicated  by  an  immediate  flooding  of 
the  pleural  cavity,  followed  by  urgent  symptoms  of  asphyxia  and 
syncope,  is  the  signal  for  immediate  operation.  Again,  repeated 
attacks  of  secondary  hemorrhage  call  for  operation. 

URGENT   THORACOTOMY 

The  technic  of  this  operation  can  be  exactly  defined  only  in  a  gen- 
eral way  and  will  need  to  be  modified  to  suit  the  individual  case. 

Lejars  insists  that  the  opening  must  be  large,  that  anything  less 
will  be  a  disappointment  and  the  operation  might  as  well  not  be 
undertaken. 

488 


THORACOTOMY  489 

The  operation  may  proceed  in  one  or  two  ways:  (i)  by  a  permanent 
resection  of  the  ribs  necessary  to  be  removed,  or  (2)  by  temporary 
resection  with  the  formation  of  a  thoracic  flap. 

(i)  Make  a  U-shaped  incision  forming  a  flap  with  its  base  posterior, 
and  of  which  the  two  arms  run  parallel  with  the  ribs  and  are  wide 
enough  apart  to  include  at  least  three  ribs. 

The  incision  reaches  to  the  ribs.  Rapidly  dissect  up  this  musculo- 
cutaneous flap,  exposing  the  ribs  and  intercostal  muscles.  With 
the  flap  held  out  of  the  way,  begin  the  resection  of  the  ribs  by  incising 
the  periosteum  of  the  lowest  rib  along  its  middle  line,  the  full  length 
of  the  exposed  part.  Denude  the  rib  with  the  rugine.  Take  special 
care  in  the  denudation  along  the  lower  border  that  the  artery  and 
nerve  removed  with  the  periosteum  are  not  wounded.  Divide  the 
inner  and  the  outer  end  of  the  denuded  segment.  (See  Operation 
for  Empyema.)     Resect  the  other  ribs  exposed  in  the  same  manner. 

Raise  the  muscido-pleural  flap.  Begin  by  dividing  the  upper  bor- 
der; then  the  lower  border;  and  finally  the  anterior  border,  catching 
each  intercostal  artery  as  cut.  When  this  flap  is  lifted  the  lung 
is  exposed. 

This  procedure  has  the  advantage  that  it  can  be  rapidly  carried 
out;  the  disadvantage,  that  it  permanently  sacrifices  a  part  of  the 
bony  wall  of  the  chest,  but  that  is  a  small  matter  in  the  face  of  such 
emergencies. 

(2)  A  thoracic  flap  may  be  formed.  Make  the  same  "U"-shaped 
incision  and  expose  the  ribs  as  in  the  preceding  operation.  Each 
costal  segment  is  then  denuded  of  periosteum  at  either  end  suJfi- 
ciently  for  the  passage  of  the  bone-cutting  forceps.  In  this  manner 
each  rib  is  divided  at  each  end. 

Next  carefully  divide  the  intercostal  muscle  parallel  with,  and 
above,  the  first  segment,  and  lift  the  anterior  end  of  this  rib,  and 
begin  the  separation  of  the  pleura. 

Work  along  the  front  at  first,  dividing  the  intercostal  muscles  and 
arteries  and  Ugating  as  necessary.  The  Uberation  of  the  flap  along 
the  lower  border  next  follows  and,  as  the  musculo-osseous  flap  is 
more  elevated,  the  separation  of  the  pleura  is  more  and  more 
facilitated. 

Finally  the  flap  is  freed  and  turned  back  and  the  pleura  is  left 


490  URGENT   THORACOTOMY 

bared.  The  pleura  is  next  divided  and  the  wounded  lung  is  now 
freely  exposed. 

Wipe  out  the  clots  and  search  for  the  bleeding  surface.  If  neces- 
sary a  hand  may  be  sUpped  under  the  base  of  the  lung  pulhng  it 
forward  for  inspection. 

Repair  the  lung.  The  ideal  method  is  by  suture,  employing  a 
No.  I  or  2  silk  thread  and  passing  it  through  the  parenchyma  with 
a  round  curved  needle.  If  this  is  not  possible  tamponade  is  the  next 
resort.  If  a  border  is  lacerated  and  projecting  it  may  be  ligated 
en  masse  and  resected. 

Whether  or  not  drainage  is  employed  depends  upon  the  amount 
of  oozing  and  the  probabilities  of  infection.  If  infection  subse- 
cjuently  develops,  the  infected  area  is  to  be  opened  and  drained  as 
any  other  empyema. 

REPAIR  OF  INJURIES  TO  PERICARDIUM  AND  HEART 

The  general  practitioner  does  not  see  many  injuries  to  the  heart. 
Gunshot  wounds  are,  of  course,  usually  immediately  fatal;  so  that 
the  form  of  cardiac  injury  most  likely  to  present  itself  for  treatment  is 
a  stab  wound.  Occasionally  the  heart  is  lacerated  by  a  broken  rib. 
The  sudden  death  from  cardiac  wounds  may  occur  in  several  ways. 
It  may  occur  from  syncope  arising  from  the  pressure  of  the  blood 
within  the  pericardium;  or  the  heart  may  be  unable  to  contract  be- 
cause of  its  divided  fibers  and  cerebral  anemia  follows;  or  shock  or 
pulmonary  edema  may  be  the  immediate  cause  of  death. 

Even  if  death  does  not  immediately  occur,  hemorrhage  and  in- 
fection may  later  provoke  a  fatal  issue  (see  Injuries  to  the  Thorax, 
page  no). 

The  treatment  of  traumatisms  of  the  heart  and  pericardium  has 
three  ends  in  view;  to  combat  shock,  to  control  hemorrhage,  and  to 
prevent  infection. 

Keep  the  patient  absolutely  quiet,  lower  the  head,  apply  artificial 
heat,  give  morphine  in  small  doses  (3^  gr.)  hypodermically;  and, 
if  there  is  an  open  wound  in  the  chest,  disinfect  and  dress  asepti- 
cally,  but  do  not  operate  merely  to  disinfect. 


THORACOTOMY 


491 


If  the  heart  is  injured  sufficiently  to  bleed,  operate.  The  sole 
indication,  then,  for  operative  treatment  is  hemorrhage. 

The  patient  will  probably  die  even  if  operated  upon,  but  he  will 
most  certainly  die  without  the  operation;  so  that  it  is  our  duty  to 
give  him  the  additional  chance  which  intervention  offers. 


Fig.  368.— Forming  the  costal  flap.  The  three  ribs  in  the  flap  are  divided  near  the  sternum, 
and  the  upper  and  lower  ribs  divided  at  the  outer  limit  of  the  flap.  The  middle  rib  to 
be  fractured  by  raising  the  flap. 


If  the  wound  seems  likely  to  have  reached  the  heart;  if  there  is 
bleeding;  if  there  is  pain  and  precordial  oppression;  if  there  are  fre- 
quent attacks  of  syncope;  if  there  are  signs  of  increase  of  fluids 
about  the  heart;  then  one  is  justified  in  believing  that  the  heart 
has  been  wounded  sufficiently  to  produce  hemorrhage  and  must 
prepare  immediately  for  the  operation.     There  must  be  no  delay. 


492  URGENT   THORACOTOMY 

Nevertheless  in  the  haste  nothing  in  the  matter  of  asepsis  must  be 
omitted. 

The  field  may  be  hurriedly  and  yet  sufficiently  prepared  by  scrub- 
bing with  alcohol  followed  by  iodine.  There  is  Uttle  use  to  stop 
the  bleeding  if  the  patient  is  to  die  later  from  sepsis  and  that  he  is 
certain  to  do  if  a  faulty  technic  is  followed. 


Fig.   369. — Costal   flap  reflected.     Pleura  retracted.    Edges  of  pericardial   wound  held 
in  forceps  and  heart  wound  exposed. 

General  Anesthesia. — Ether  should  be  employed  if  the  patient's 
CO  idition  will  permit. 

The  operation  proposes  to  make  a  thoracic  flap,  to  open  the 
pericardium  and  expose  the  heart,  and  to  repair  the  injury. 
There  is  no  operation  that  requires  more  decision,  courage,  and 
self-control. 

Incision. — Begin  in  the  third  intercostal  space  just  in  front  of  the 


EXPOSING    THE   HEART 


493 


anterior  axillary  border  and  cut  inward  to  the  border  of  the  sternum 
abruptly  curving  there  and  following  the  sternal  border  downward 
to  the  sixth  space;  again  abruptly  curving  and  following  that  space 
outward  (Fig.  368).  These  incisions  expose  the  ribs  and  intercostal 
muscles. 


Fig.  370. — Heart  supported  in  palm  of  hand  preparatory  to  suturing.     {Ajter  Lejars.) 


Formation  of  the  Flap. — Divide  the  fourth,  fifth,  and  sixth  carti- 
lages near  the  sternum  and  also  the  intercostal  muscles,  along  the 
line  of  the  original  incision. 

At  the  lower  outer  angle  of  the  incision,  expose  the  sixth  rib  by 
pulling  the  tissues  upward.     Incise  the  periosteum  over  its  external 


494 


URGENT   THORACOTOMY 


surface  and  with  the  rugine  free  the  rib  of  periosteum  and  divide  it. 
At  the  upper  outer  angle  expose  the  fourth  rib,  free  it  of  periosteum, 
and  with  the  costotome  or  a  bone-cutting  forceps,  divide  it  in  the 
same  way.  The  flap  is  now  attached  only  by  the  fifth  rib  which  is 
to  be  fractured.  Raise  the  sternal  end  of  the  flap  with  the  left  hand 
and  press  on  the  fifth  rib  with  the  right  hand  and  with  a  little  force 
the  rib  is  broken  in  the  Hne  of  section  of  the  other  two  ribs. 

The  flap  is  now  gradually  raised  as  its  adhesions  to  the  subjacent 
structures  are  freed,  and  the  pleura  is  exposed. 

If  there  is  a  wound  in  the  pleura,  enlarging  it,  the  pericardium  may 
be  reached;  otherwise  proceed  to  the  liberation  and  retraction  of  the 


¥  ^" 

-  -  ■  -  - 

'^'i 

>s 

^ 

J 

\ 
\ 

fe.. 

3r  H 


Fig.  371. — Suture  of  wound  of  heart.  Fig.  372. — Suture  of  heart  completed. 


pleura.  With  a  grooved  director,  liberate  the  fibrous  attachments 
of  the  triangularis  sterni  to  the  posterior  surface  of  the  sternum, 
which  at  the  same  time  liberates  the  pleura.  With  the  fingers,  draw 
outward  the  free  border  of  the  pleura  with  its  covering,  the  triangu- 
laris sterni  (Fig.  369).  In  this  manner  is  the  pericardium  exposed. 
The  assistant  holds  the  pleura  with  a  retractor. 

Incision  oj  the  Pericardium. — Enlarge  the  wound  in  the  pericardium 
and  in  that  manner  expose  the  heart.  Retract  the  edges  of  the  peri- 
cardial wounds  with  forceps.  Locate  the  wound  in  the  heart.  Slip 
the  left  hand  under  the  apex  and  pass  the  first  suture,  and  the  heart 
may  be  thereafter  steadied  by  traction  on  the  threads  of  the  first  suture 
(Fig.  370). 


SUTURING   THE   HEART 


495 


Suture  the  ivound  in  the  heart.  Use  either  interrupted  or  continuous 
suture  of  catgut.  There  is  no  particular  advantage  in  passing  the 
suture  in  diastole.  Pass  them  deeply,  but  not  to  the  endocardium 
(Figs.  371,  372). 

Now  wipe  out  the  pericardial  cavity  with  sterile  compresses  and 
repair  the  pericardium  by  continuous  catgut  suture.  Next,  wipe  out 
the  adjacent  portion  of  the  pleural  cavity,  repair  any  part  of  the  lung 
that  may  be  injured  and  repair  the  pleura  without  drainage.  Finally, 
replace  the  thoracic  flaps,  and  suture.  It  is  generally  wise  to  excise 
the  tissues  along  the  track  of  the  wound. 

No  drainage  is  to  be  employed  except  under  these  circumstances: 
if  the  case  was  operated  on  late  and  there  is  great  probability  of 
infection,  it  is  better  to  leave  drainage  in  the  pleural  wound,  pro- 
jecting from  the  thorax  at  the  lower  angle  of  the  skin  wound;  if  there 
is  much  oozing,  it  is  better  to  leave  a  wick  of  gauze  in  the  pleural 
wound. 

A  case  of  successful  suture  by  Gibbon,  of  Jefferson  Medical 
College,  illustrates  the  subject  (Jour.  American  Medical  Assn.,  Feb. 
10,  1906).  Patient,  aged  thirty-eight,  healthy  colored  man.  Stab 
wound  of  chest,  a  few  moments  after  which  he  fell  unconscious.  An 
hour  later  at  the  hospital  his  condition  was  very  grave :  unconscious, 
cyanosed,  pupils  dilated,  skin  cold  and  moist,  respiration  rapid  and 
shallow.  No  pulse  in  the  peripheral  vessels  and  the  heart  sounds 
were  distant,  rapid,  and  irregular. 

Vigorous  stimulation  was  employed  with  morphine  and  atropine 
and  his  condition  slightly  improved.  Operation  about  one  and  one- 
haK  hours  after  the  injury.     Only  a  small  quantity  of  ether  required. 

The  fourth  costal  cartilage  was  found  and  divided  and  the  entire 
cartilage  and  a  part  of  the  rib  was  removed.  The  pericardium 
was  explored  and  a  wound  located  which  would  only  admit  tip  of  in- 
dex finger.  This  pericardial  wound  was  enlarged  and  the  sac  emp- 
tied of  clots  and  liquid  blood.  It  began  rapidly  to  fill  again.  Two 
fingers  passed  under  the  heart  lifted  it  up  into  the  pericardial  open- 
ing and  with  rapid  sponging,  the  wound  was  located.  It  was 
situated  in  the  right  ventricle  near  the  auriculo-ventricular  groove. 
It  bled  freely,  controlled  by  pressure;  was  about  %  inch  in  length. 
The  wound  in  the  endocardium  was  about  one-half  as  long. 


496  URGENT   THORACOTOMY 

A  traction  suture  of  chromicized  catgut  was  passed  through  both 
edges  and  by  that  means  the  heart  was  held  in  position,  while  four 
other  sutures  were  passed  and  no  effort  was  made  to  avoid  the  en- 
docardium. A  small  gauze  drainage  w^as  applied  to  the  Une  of 
sutures  and  brought  out  through  the  pericardial  wound  which  was 
not  sutured. 

During  the  subsequent  twelve  hours  there  was  enough  oozing 
to  require  a  change  of  dressing.  His  general  condition  was  fairly 
good.  The  second  day  his  condition  was  alarming;  respirations  62. 
The  gauze  was  found  to  be  interfering  with  drainage  and  removed. 
The  respirations  fell  to  38  in  a  short  time. 

Large  quantities  of  salt  solution  were  given  by  rectum.  Liquid 
food  on  second  day.  The  dressings  were  changed  every  other  day. 
Six  days  after  the  operation  the  skin  wound  was  sutured  almost  com- 
pletely, the  wound  in  the  pericardium  being  practically  healed. 
In  six  weeks  he  returned  to  work  completely  recovered,  with  heart's 
action  regular  and  normal. 

Gibbon  does  not  advise  an  osteo-plastic  flap  unless  a  pleural  wound 
is  demonstrated,  believing  it  best  to  excise  as  much  of  the  sternum 
or  cartilage  or  rib  as  may  be  necessary  to  give  free  access.  He  em- 
phasizes the  value  of  the  traction  suture,  and  advises  the  repair  of 
the  pericardial  wound  without  drainage,  but  would  always  drain  the 
external  wound. 

Travers  (Lancet,  Sept.,  1906)  operated  upon  a  case  in  which  the 
patient  was  impaled  upon  a  spike  fence.  The  right  ventricle  was 
torn,  the  spike  penetrating  the  sternum  to  reach  it.  The  wound 
in  the  heart  was  closed  by  twenty  sutures.  The  patient  did  very  well 
up  to  the  eleventh  day,  when  he  died  from  heart  failure,  due  to  the 
pressure  of  a  slowly  forming  clot. 

Travers  notes  that  the  suturing  seemed  to  stimulate  the  flagging 
heart. 

Stewart,  among  the  first  in  the  United  States  to  suture  the  heart 
successfully,  turned  the  musculo-cutaneous  flap  to  the  left  and  the 
thoracic  flap  to  the  right,  fracturing  the  cartilages  near  the  base  of  the 
sternum. 

The  pericardial  wound  was  enlarged  in  the  axis  of  the  heart.  The 
heart  wound,  produced  by  a  stab  with  a  long,  rusty  pen-knife,  involved 


SUTURING   THE  HEART  497 

the  thickness  of  the  left  anterior  ventricular  wall,  ran  parallel  with  the 
axis  of  the  lieart,  and  was  about  J^  inch  in  length,  was  larger  than 
either  the  skin,  pleural,  or  pericardial  wound.  The  heart  bled  freely 
and  continuously,  and  resembled  a  mere  quivering  mass  of  muscle. 

The  wound  was  closed  with  a  continuous  silk  suture,  the  pericardial 
cavity  cleansed  and  the  sac  sutured  with  silk.  A  gauze  drain  was 
left  at  the  lower  angle.  The  pleural  cavity  was  cleansed  and  irri- 
gated with  salt  solution.  The  thoracic  flaps  were  sutured  with  silk- 
worm-gut and  a  gauze  drain  left  also  in  the  pleural  cavity. 

During  the  operation,  which  lasted  about  forty-five  minutes, 
24  ounces  of  salt  solution  and  adrenalin  were  injected,  and  strychnin 
and  atrophin  given  hypodermically. 

Some  infection  followed,  and  by  the  eighth  day,  the  temperature 
was  103°,  pulse  150,  and  respiration  50.  From  that  time,  the  symp- 
toms of  sepsis  gradually  declined  until  at  the  end  of  three  weeks,  these 
conditions  were  practically  normal;  at  the  end  of  the  fifth  week,  the 
patient  was  out  of  bed. 

Stewart,  discussing  the  operation  (American  Journal  Med.  Sci- 
ences, Sept.,  1904),  notes  that  the  size  of  the  heart  wound  cannot  be 
predicted  from  the  external  wound;  and  concludes  that  the  only  safe 
procedure  in  doubtful  cases  is  to  enlarge  the  wound  and  ascertain  if  it 
penetrates  the  chest  wall;  and  if  there  be  symptoms  of  hemorrhage — ■ 
of  heart  tamponade — -operate. 

In  all  of  these  cases  already  mentioned,  it  was  the  ventricle  which 
required  repair.  Peck,  of  New  York,  describes  a  case  in  which  it  was 
necessary  to  suture  the  auricle  (Annals  of  Surgery,  July,  1909). 

The  patient,  a  colored  girl  twenty-four  years  of  age,  was  brought 
to  the  hospital  suffering  from  a  stab  wound  over  the  third  costal  carti- 
lage at  the  left  border  of  the  sternum.  Her  condition  was  grave: 
no  radial  pulse;  the  heart  sounds  could  not  be  heard;  respiration  faint 
and  shallow,  and  the  extremities  cold;  operation  begun  about  forty- 
six  minutes  after  the  receipt  of  the  injury. 

A  quadrangular  flap  of  the  soft  parts  with  base  external  was  dis- 
sected back.  The  third,  fourth,  fifth  and  sixth  cartilages  were  di- 
vided at  the  sternal  junction,  and  the  third,  fourth,  and  fifth  ribs  near 
the  costo-chondral  junction,  and  the  flap  turned  out  and  the  internal 
mammary  Hgated  above  and  below.  The  pericardial  wound  was 
32 


498  URGENT   THORACOTOMY 

near  the  border  of  the  sternum,  a  part  of  which  was  resected  with 
rongeur  forceps  to  give  a  better  view.  The  tense  pericardium  was 
incised  and  the  clots  emptied  out,  whereupon  the  radial  pulse  could 
be  felt. 

The  bleeding  seemed  to  come  from  the  upper  part  of  the  cavity  but 
the  rapidly  beating  heart,  churning  the  free  blood,  made  it  impossible 
to  locate  the  wound  until  a  transverse  cut  in  the  sac  gave  a  better 
exposure. 

Lifting  the  heart  forward  and  sHghtly  rotating  it  to  the  left,  a 
wound  of  the  right  auricle  was  brought  into  view.  With  each  systole 
a  stream  of  dark  blood  spouted  2  or  3  inches.  Four  sutures  of 
chromicized  catgut  passed  on  a  curved  intestinal  needle  controlled 
the  bleeding.  The  pericardium  was  cleansed,  close  without  drainage 
with  continuous  chromic  catgut  suture.  The  cartilaginous  flap  was 
carefully  sutured  with  No.  3  chromicized  gut  and  the  soft  parts  with 
catgut  and  silkworm-gut.  No  drainage  was  used.  The  operation 
lasted  sixty-five  minutes,  during  which  time  1900  C.  of  normal  salt 
solution  was  given  intravenously.  For  the  first  six  or  seven  days 
there  were  signs  of  mild  pleurisy  and  the  temperature  ranged  from. 
100  to  102.8,  pulse  116  to  136;  but,  at  the  end  of  two  weeks,  these 
were  practically  normal,  and  at  the  end  of  another  week,  she  was  dis- 
charged, quite  well. 

It  will  be  observed  that  the  incision  and  flap  formation  differed 
with  each  operation,  no  one  method  can  be  insisted  upon  to  the  ex- 
clusion of  all  others. 

PUNCTURE  OF  THE  PERICARDIUM 

Puncture  of  the  pericardium— paracentesis  pericardii — -is  indicated 
in  those  cases  of  hemo-pericardium  and  serous  effusion  in  which 
the  accumulating  fluids  dangerously  interfere  with  the  functions  of 
the  heart.  The  physical  signs  and  the  symptoms  point  to  the  nature 
of  the  difficulty.  The  symptoms  may  be  overlooked  in  those  which 
pertain  to  the  primary  infection.  The  patient  breathes  with  diffi' 
culty  and  complains  of  pain  and  tenderness  over  the  heart,  the  pain 
radiating  down  the  left  arm  or  the  epigastrium;  the  temperature  is 
variable;  there  is  leucocytosis. 


PUNCTURE   OF   THE   PERICARDIUM  499 

The  physical  signs  arc  significant:  The  pulse  is  weak  and  rapid, 
there  is  often  precordial  bulging;  the  dullness  of  the  heart  area  is 
increased  the  heart  sounds  are  faint;  and  in  some  cases  the  first  rib 
is  pushed  away  from  the  clavicle  (Ewart's  sign).  The  exploratory 
puncture  will  confirm  the  diagnosis.  It  is  not  more  frequently 
done  because  of  the  instinctive  fear  that  one  may  wound  the  heart; 
indeed  there  are  three  structures  which  may  be  wounded  with  serious 


Fig.  373- — Puncture  of  the  pericardium  and  pericardiotomy;  vertical  lines,  represent  the 
anterior  border  of  pleura  and  lung.  The  •  represents  sites  of  puncture.  ■■",  line  of 
incision  for,  and  portion  of  rib  resected  in;  pericardiotomy. 


consequences;  the  heart,  the  pleura,  and  the  internal  mammary 
artery. 

The  puncture  may  be  made  near  the  sternum  to  the  inside  of  the 
internal  mammary;  it  may  be  made  to  the  outside  of  the  internal 
mammary,  between  it  and  the  line  of  the  lung.  The  latter  is  perhaps 
the  better  (Fig.  373). 

The  point  of  entrance  of  the  needle  is  in  the  fifth  left  intercostal 
space,  6  cm.  from  the  sternal  border.     Use  a  small  trocar  or  an  as- 


500  URGENT   THORACOTOMY 

pirator.  Cleanse  the  field  thoroughly.  Put  the  patient  in  a  half 
reclining  position  on  his  bed  and  mark  with  the  left  index  finger  the 
site  of  the  puncture. 

Direct  the  needle  obliquely  downward  and  inward  and  do  not 
penetrate  deeper  than  2.5  cm.,  holding  the  needle  so  as  to  regulate 
its  progress. 

As  the  pericardium  empties  itself,  gradually  elevate  the  trocar  so 
as  not  to  wound  the  heart. 

PURULENT  PERICARDITIS.     PERICARDIOTOMY 

If  in  addition  to  the  physical  signs  pertaining  to  effusion,  there  are 
edema  of  <he  chest  wall  and  the  symptoms  of  sepsis  it  is  almost 
certain  a  purulent  pericarditis  is  to  be  dealt  mth  and  if  the  explora- 
tory puncture  demonstrates  the  presence  of  pus,  the  only  rational 
treatment  is  drainage,  unless  the  patient  is  moribund.  To  incise 
and  empty  the  pericardium  is  the  only  procedure  that  offers  any 
hope  of  permanent  relief. 

Operation. — Begin  by  locating  the  attachment  of  the  fifth  costal 
cartilage  and  the  middle  of  the  sternum. 

Incision. — From  the  middle  of  the  sternum  horizontally  outward 
over  the  center  of  the  fifth  cartilage  on  the  left  side,  to  the  costo- 
chondral  junction.  Deepen  the  incision  so  as  to  divide  all  the  soft 
parts  down  to  the  cartilage.  Strip  back  the  covering  of  the  cartilage 
with  the  rugine  (Fig.  373). 

Resect  the  cartilage  at  its  sternal  junction  and,  gently  lifting  up, 
gradually  detach  its  coverings  behind  out  to  the  junction  of  the  rib. 
Here  it  may  be  fractured  or  permanently  resected.  Dividing  their 
sternal  attachments,  retract  the  intercostal  muscles  with  the  arteries 
in  the  space  opened  up  and  thus  expose  the  pleura. 

Detach  the  pleura  by  loosening  the  sternal  attachments  of  the  tri- 
angularis which  allows  the  pleura  to  be  drawn  outward.  This 
should  be  done  with  the  finger  passed  under  the  sternum  and  hooked 
around  the  border  of  the  pleural  sac.  The  pericardial  sac  is  now 
exposed. 

Incise  the  pericardium,  first  catching  up  a  fold  between  two  forceps, 


PERICARDIOTOMY  50I 

and  dividing  it  with  scissors.     If  possible,  the  edges  of  the  pericardial 
wound  should  be  stitched  to  the  margin  of  the  skin  wound. 

Insert  gauze  drainage:  A  rubber  tube  is  too  likely  to  irritate  the 
heart.  This  operation  is  often  followed  by  recovery  without  any 
impairment  of  the  heart's  action. 


CHAPTER  III 
EMPYEMA— PURULENT  PLEURISY 

Various  bacteria  may  attack  the  pleura,  most  frequently  they  are 
the  pneumococcus,  the  streptococcus,  the  staphylococcus,  the 
bacillus  tuberculosis,  or  the  bacillus  communi  coli. 

The  pneumococcus  is  usually  present  in  the  empyema  of  childhood. 
Be  on  your  guard  for  empyema  especially  in  whooping-cough. 

The  clinical  history  and  the  prognosis  vary  in  different  forms  of 
the  disease  and  are  directly  dependent  upon  the  form  of  the  infection. 

But,  whatever  the  pyogenic  agent,  when  pus  has  once  formed  in 
the  pleural  cavity,  it  seeks  for  an  outlet  in  various  directions.  It 
may  rupture  into  a  bronchus  and  escape  by  the  mouth,  and,  under 
these  circumstances,  pneumothorax  may  ensue;  it  may  perforate 
the  chest  wall,  manifesting  itself  as  an  external  abscess  of  various 
forms;  it  may  open  into  the  pericardium,  esophagus,  or  stomach. 

In  every  case,  the  longer  relief  is  delayed,  the  greater  the  proba- 
bility that  the  lung  will  be  permanently  collapsed  or  bound  down 
by  adhesions.  Finally,  in  some  degree,  there  are  always  the  evil 
results  of  sepsis.  There  is  every  reason,  then,  when  pus  is  known  to 
exist  in  the  pleural  cavity,  to  drain  without  delay. 

The  diagnosis  rests  upon  the  history  of  the  case  (remembering  that 
this  history  will  vary  with  the  form  of  infection),  upon  the  pain,  the 
constitutional  symptoms  which  are  those  of  sepsis  generally,  and 
upon  the  physical  signs.  These  are:  distention  of  the  thorax  ac- 
companied perhaps  by  edema  of  the  chest  wall;  flatness  on  percussion 
and  evident  displacement  of  neighboring  organs;  absence  of  the 
vesicular  murmur,  and  the  presence  of  bronchial  breathing. 

Taylor,  of  Springfield  (Illinois  Med.  Jour.,  1907),  attributes  the 
most  frequent  source  of  error  in  diagnosis  to  a  misconception  of  the 
position  assumed  by  the  exudate. 

Physicians  are  observed  trying  to  establish  a  horizontal  line  for 

502 


EXPLORATORY   PUNCTURE 


503 


the  exudate  with  the  patient  in  the  sitting  posture,  under  the  im- 
pression that  the  fluid  will  follow  the  influence  of  gravity.  But  this 
is  the  exception  rather  than  the  rule.  The  dullness  is  usually  higher 
posteriorly.  The  "S  "-shaped  line  of  Ellis,  if  present  at  all,  is  so 
variable  from  day  to  day  as  to  be  of  minor  importance.  Taylor 
remarks  further  that  the  character  of  the  fluid  is  often  a  matter  of 
doubt.     Chills  and  variable  temperature  point  to  pus,  although  he 


Fig.  374. — Puncture  of  the  pleura.     {Lejars.) 

has  seen  patients  recovering  from  pneumonia  who  had  none  of  these 
symptoms  and  yet  carried  around  three  pints  of  pus  in  the  pleural 
cavity. 

Most  of  the  signs  and  symptoms  may  occur  as  well  with  pleurisy 
with  effusion,  and  it  is  only  by  exploratory  puncture  that  the  matter 
may  be  definitely  determined. 

Exploratory  puncture,  then,  is  the  court  of  final  resort  and  must 
always  be  employed  before  deciding  upon  the  form  of  treatment. . 


S04 


EMPYEMA — ^PURULENT   PLEURISY 


PUNCTURE  OF  THE  PLEURA 


Let  the  patient  lie  on  the  sound  side  with  his  shoulders  elevated 
and  the  arm  of  the  affected  side  extended  above  the  head,  the  effect 
of  which  is  to  widen  the  intercostal  spaces.  Locate,  for  example,  a 
point  in  the  axillary  line  and  the  sixth  intercostal  space.  Freeze  the 
skin  with  ethyl  chloride  or  inject  a  little  cocaine  at  the  site  of  punc- 
ture. Press  a  finger  into  the  intercostal  space  and  locate  the  lower 
border  of  the  rib.  With  the  finger  as  guide  enter  the  needle  so  as  to 
avoid  the  rib  and  thrust  it  inward  and  slightly  upward.  One  can 
readily  determine  whether  it  has  reached  the  pleural  cavity  by  the 
degree  of  resistance.  Enough  fluid,  whether  pus 
or  serum,  will  escape  through  the  aspirating  needle 
to  make  its  presence  certain;  but  in  order  to  draw 
off  any  quantity  an  aspirator,  of  which  Potain's 
(Fig.  374)  is  the  best  type,  must  be  attached.  A 
serous  pleuritic  effusion  is  relieved  by  aspiration. 
Sometimes  removal  of  even  a  small  quantity  will 
start  absorption  in  a  case  of  long  standing.  If  the 
fluid  is  pus,  the  subsequent  course  of  events  is 
quite  different. 

As  has  been  said,  every  purulent  pleurisy  must 
be  opened  as  soon  as  possible,  must  be  opened 
freely  and  at  its  lower  point. 

In  the  case  of  a  child,  it  suffices  usually  to  in- 
cise the  intercostal  space  in  order  to  perfect  a 
cure.  In  the  case  of  the  adult,  it  is  necessary  to  resect  a  rib  for 
adequate  drainage,  and  even  then  the  patient  may  shortly  die  or 
retain  a  chronic  sinus.  These  possibilities  should  always  be  ex- 
plained before  the  operation,  necessary  but  disagreeable,  is  under- 
taken. 

Site  of  the  Incision. — The  cavity  must  be  opened  where  it  will  drain 
best  in  the  recumbent  position.  The  lowest  level  of  the  abscess  can 
be  determined  only  by  exploratory  puncture;  any  other  method  is 
useless.  Having  already  confirmed  the  diagnosis  by  puncture,  now 
at  the  beginning  of  the  operation,  make  another  exploratory  punc- 
ture in  the  space  next  lower.     If  pus  is  found  there,  puncture  again 


Fig.  375- — Em- 
pyema: Relation  of 
the  pus  cavity  to 
the  chest  wall  and 
lung.     {Veau.) 


INCISION   OF   THE   PLEURA  505 

in  the  space  below,  and  so  on  until  no  pus  is  found.     The  last  punc- 
ture producing  pus  will  be  the  site  of  the  incision. 

Anatomy  (Fig.  375). — The  aim  will  be  to  incise  parallel  with  the 
rib.  In  going  through  the  structures  of  the  intercostal  space,  re- 
member that  the  vessels  and  nerve  lie  in  or  near  the  groove  in  the 
lower  border  of  the  rib.  Incising  any  space,  therefore,  keep  close 
to  the  lower  line  of  the  space,  keep  near  the  upper  border  of  the  rib 
forming  the  lower  boundary  of  the  space.  If  a  rib  is  to  be  resected, 
it  should  be  denuded  of  its  periosteum,  which  is  loosely  attached  and 
on  that  account  easily  stripped  off. 

EMPYEMA  IN  THE  CASE  OF  A  CHILD 

In  the  case  of  a  child,  simple  incision  of  the  pleura  will  suffice. 
Under  general  anesthesia,  if  the  condition  of  the  patient  will  permit, 
make  an  incision  3  or  4  inches  long,  parallel  with  the  ribs. 
The  incision  traverses  the  skin,  and  beneath  it  a  cellular  layer,  often 
edematous.     Next  divide  the  muscles,  letting  the  rib  serve  as  a  resist- 


FiG.  376. — Incision  of  the  pleura  without  resection  of  a  rib.    {Schwartz.) 

ing  plane.  In  front  they  are  thin  (pectoralis  major) ;  behind,  thicker 
(latissimus  dorsi  and  serratus  magnus).  Divide  them  at  a  single 
stroke  and  without  concern.  A  small  artery  may  need  to  be  clamped. 
Having  exposed  the  rib  (Fig.  376),  retract  the  upper  lip  of  the 
wound  and  locate  the  upper  border  of  the  rib;  below,  it  bounds  the 
space  about  to  be  penetrated.  Following  this  border,  incise  layer 
by  layer,  the  intercostal  muscles.  There  is  never  any  serious  hemor- 
rhage. As  you  approach  the  pleura,  be  prepared  for  a  sudden  spurt 
of  pus,  and,  when  the  pus  flows,  it  is  evident  the  pleura  is  opened. 
Enlarge  the  opening,  using  the  left  index  finger  as  a  guide.  Incline 
the  patient^so  that  the  cavity  may  be  entirely  emptied.  Fix  the 
drainage-tube  (Fig.  382). 


5o6  EMPYEMA — PURULENT  PLEURISY 

EMPYEMA  IN  THE  CASE  OF  AN  ADULT 

In  the  case  of  empyema  in  an  adult,  it  is  usually  necessary  to  resect 
a  rib.  One  needs  a  bone-cutting  forceps  or  a  costotome  and  a  curved 
periosteal  elevator  or  rugine  in  addition  to  the  ordinary  instruments. 


Fig.  377. — Incision  of  the  costal  periosteum.     (Veau.) 

Local  anesthesia  is  preferable  and  with  a  little  patience  will  be 
made  to  serve.  Having  determined  the  line  of  the  incision  inject 
with  novocain,  intradermically.     Next  infiltrate  the  subcutaneous 


Fig.  378. — Uncovering  the  posterior  surface  of  the  rib  with  rugine.    {Schwartz.) 

tissues  along  the  same  line.     Usually  after  a  wait  of  five  minutes  the 
skin  and  fascias  may  be  divided  without  pain. 

An  injection  is  next  made  in  the  periosteum  and  the  tissues  ad- 
jacent to  the  site  to  be  sectioned.  With  the  timorous,  ether  may  be 
necessary  but  it  can  never  be  considered  safe  in  such  conditions. 


RESECTION   OF   THE   RIB 


507 


Having  deLermined,    then,   the   site   of  incision   by   exploratory 
puncture,  incise  the  skin  and  muscles  as  in  the  case  of  a  child.     The 


Fig.  379. — Section  of  the  rib.     (Schwartz.) 

length  of  the  incision  will  equal  four  fingers'  breadth.     When  the 
rib  is  exposed,  divide  its  periosteum  in  the  middle  line  (Fig.  377). 

The  denudation  of  the  rib  is  an  important  step.  With  the  rugine 
or  curved  periosteal  elevator,  uncover  the  upper  half  of  the  external 
surface  of  the  rib  first  and  then  the  lower  half,  keeping  very  close  to 


Fig.  380. — Section  of  the  rib.     (Schwartz.) 

the  rib  as  you  reach  the  lower  border,  so  as  not  to  wound  the  inter- 
costal vessels  or  nerve,  which  are  closely  attached  to  the  periosteum 
and  are  removed  with  it.  Finally,  "uncover  the  deep  surface  of  the 
rib.  Carefully  slip  the  elevator  upward  between  the  bone  and  its 
periosteum,  which  is  loosely  attached  (Fig.  378).  Carry  the  elevator 
to  one  end  of  the  section  and  then  to  the  other  and  the  part  of  the 
rib  to  be  removed  is  thus  entirely  freed  from  its  periosteal 
attachment. 


5o8 


EMPYEMA — PURULENT  PLEURISY 


Divide  the  rib.     Introduce  one  blade  of  a  bone  forceps  or  costotome 
under  one  end  of  the  section  to  be  removed  and  divide  it  (Fig.  379). 

*  s 


Fig.  381. — Rib  removed,  pleura  incised.    (,Veau.) 

Then  divide  the  other  end  (Fig.  380).  The  bone  removed  should  be 
2M  to  3  inches  long.  The  stumps  should  not  project  beyond  the 
limit  of  the  flesh  wound,  else  necrosis  is  favored. 

Incise  the  pleura.     With  the  rib  removed,  the  periosteum  remains 
attached  to  the  pleura  and  this  periosteal  layer  is  incised  along  its 


Fig.  382. — Drainage  of  the  pleural  cavity.    {Yean.) 

middle  (Fig.  381),  and  the  pleura  is  divided  at  the  same  time.     Be 
on  your  guard,  when  making  the  incision,  for  a  spurt  of  pus. 

Empty  and  drain  the  cavity.  Incline  the  patient  to  one  side  and 
instruct  him  to  cough.  The  pus  pours  out,  often  offensively  fetid. 
Take  plenty  of  time.  Finally,  wipe  out  the  cavity  with  sterile  gauze. 
Irrigation  is  usually  inadvisable;  but,  if  used,  employ  only  warm, 
sterile  water,  salt  solution,  or  a  weak  solution  of  peroxide.  The 
stronger  antiseptics  are  dangerous.  Do  not  suture  the  wound  except 
to  cover  over  the  projecting  end  of  the  divided  rib.  The  difficulty 
is  to  keep  the  wound  open. 


DRAINAGE  509 

Drainage  must  never  be  neglected.  Employ  two  large  and  long 
tubes  placed  in  different  directions  and  anchor  with  safety-pins  (Fig. 
382)  or  by  a  suture,  else  they  may  be  lost  in  the  abscess  cavity. 

Dressing. — 'This  is  important.  Pack  moist  sterile  or  boracic 
gauze  all  around  the  tubes,  between  the  lips  of  the  wound.  Apply 
an  ample  dressing  of  absorbent  cotton,  which  covers  half  the  thorax, 
and  hold  all  in  place  with  a  large  flannel  bandage  maintained  by 
suspenders.  Let  the  patient  occupy  the  half-sitting  position,  in- 
clined toward  the  affected  side  and  supported  by  pillows  at  the 
back. 

Subsequent  Care. — After  a  few  hours,  change  the  dressing,  which  is 
usually  saturated,  but  do  not  disturb  the  drains.  Change  the  dress- 
ing twice  daily  until  the  discharge  diminishes  and  about  the  third 
day  withdraw,  cleanse,  and  replace  the  tubes  in  the  same  place  and  to 
the  same  depth;  else  look  for  trouble,  if  you  fail  to  accomplish  this. 

Do  not  irrigate  while  making  these  dressings,  unless  the  discharge 
has  persisted  undiminished  for  a  week  and  continues  fetid,  when  it  is 
best  to  use  a  sterile  wash  of  salt  solution  or  dilute  peroxide,  which 
is  to  be  injected  under  very  sHght  pressure. 

The  end  results  vary  with  the  nature  of  the  infection. 

(i)  The  meta-pneumonic  pleurisy  of  children  is  usually  cured. 
About  the  fifteenth  day,  smaller  tubes  may  be  used  and  are  gradually 
to  be  shortened  as  granulation  proceeds.  In  the  fortunate  case,  the 
opening  will  close  in  something  like  two  months. 

(2)  In  tubercular  pleurisy  with  secondary  infection,  cure  scarcely 
ever  takes  place.  The  patient  will  probably  die  in  a  few  months  of 
amyloid  degeneration.  Even  if  the  patient  does  not  die  soon,  the 
suppuration  shows  little  tendency  to  yield.  In  these  cases  with  per- 
sistent sinus,  the  bismuth  paste  injection  often  hastens  a  cure. 

(3)  Streptococcic  or  staphylococcic  pleurisy:  The  patient  may  go 
on  to  death  or  else  recovers  with  persistent  sinus.  Keep  the  orifice 
open,  for  if  the  pus  is  allowed  to  accumulate,  it  will  be  necessary  to 
operate  again.  Keep  watch  on  the  functions  of  the  kidney  and 
liver.  Remember  the  frequency  of  metastatic  abscess,  as  of  the 
brain,  for  example. 

After  two  to  four  months,  the  case  may  be  referred  to  a  specialist 
for  a  plastic  operation. 


CHAPTER  IV 
URGENT  CRANIECTOMY:  TREPHINING 

FRACTURE  OF  VAULT  OF  THE  SKULL 

There  are  two  conditions  which  may  accompany  fracture  of  the 
skull,  singly  or  together,  either  of  which  demands  immediate  relief. 
(See  Fracture  of  the  Skull.) 

(A)  The  depressed  fragments  have  contused  and  lacerated  the 
brain;  consciousness  was  immediately  lost  and  was  not  regained. 
Under  these  circumstances,  the  fragments  must  be  elevated  without 
delay. 

(B)  Hemorrhage  has  occurred  within  the  cranial  cavity  and  the 
clot  compresses  the  brain.  In  this  case,  there  is  a  "free  interval." 
The  patient  regains  consciousness  and,  perhaps,  for  a  time — 'two  to 
twenty-four  hours — 'appears  not  to  be  seriously  injured,  but  little  by 
little  the  signs  of  "compression"  develop,  namely:  restlessness,  dull- 
ness, stupor,  coma;  normal  pulse  at  first,  but  which  finally  grows  slow, 
full  and  bounding;  and  slow  and  stertorous  breathing.  Delay  is 
dangerous.     The  clot  must  be  removed  and  the  hemorrhage  checked. 

Nearly  always  it  is  the  middle  meningeal  which  is  at  fault.  There 
is  in  consequence  an  extradural  hematoma.  Once  in  a  while,  however, 
the  bleeding  will  be  found  to  proceed  from  a  ruptured  sinus  or  from 
the  pial  arteries  and  there  exists  at  the  same  time  an  injury  to  the 
brain  substance.  There  is,  in  this  case,  an  intradural  or  intracerebral 
hematoma. 

Whatever  the  form  of  compression,  one  is  compelled  to  operate, 
but  he  must  first  get  the  anatomy  of  the  middle  meningeal  artery 
clearly  in  mind. 

The  middle  meningeal,  a  branch  of  the  internal  maxillary,  is  the  size  of  the 
radial,  entering  the  cranial  cavity  at  the  base  of  the  skull,  through  the  foramen 
spinosum.     It  is  embedded  in  the  dura  and  grooves  the  inner  surface  of  the  skull. 

Above  the  level  of  the  zygoma,  the  artery  divides.     The  posterior  branch 


TREPHINING 


Sii 


the  smaller,  is  directed  upward  and  backward,  and  the  anterior  branch  (Fig. 
383),  the  more  important,  ascends  vertically  to  the  fronto-parietal  suture, 
which  it  follows  upward,  passing  a  little  posterior  to  it.  As  it  reaches  this  suture, 
it  gives  off  constantly  a  posterior  branch.  The  anterior  branch  is  accompanied 
by  veins  which  occasionally  assume  the  importance  of  a  sinus. 

The  directions  for  trephining  over  the  middle  meningeal  are  quite  definite, 
but  usually  unnecessary  to  regard  in  emergency  surgery,  for  it  is  a  mistake 
not  to  follow  the  exterior  indications  and  guides  furnished  by  the  traumatism. 
Still  one  should  be  able  to  locate  these  points  readily. 

Two  horizontal  and  two  vertical  lines  are  employed  to  locate  the  paths  of  the 
two  branches  of  the  middle  meningeal.  Dr^w  the  first  (A)  from  the  inferior 
border  of  the  orbit  along  the  zygoma  to  the  external  meatus.  Draw  the  second 
(B)  from  the  upper  border  of  the  orbit  back- 
ward, and  parallel  with  the  first,  ending  be- 
yond the  line  of  the  mastoid.  To  locate  the 
path  of  the  anterior  branch  of  the  middle 
meningeal,  draw  a  perpendicular  line  from  A 
upward  from  a  point  corresponding  to  the 
middle  of  zygoma;  and  where  it  cuts  B  is 
the  point  most  advantageous  for  exposing 
the  anterior  branch.  This  vertical  line  is 
about  two  inches  in  length  or  approximately 
equal  to  the  length  of  the  last  two  joints  of 
the  index  finger.  To  locate  the  track  of  the 
posterior  branch :  From  the  apex  of  the  mas- 
toid, draw  a  second  vertical  line  upward;  its 
point  of  junction  with  B  indicates  the  path 
of  the  posterior  branch.  These  lines  may  be  marked  off  on  the  skin  by  tincture 
of  iodine. 


Fig.  383- 
meningeal 
Cuneo.) 


-Outline   of  the  middle 
artery.      {Veau      after 


Operation. — -Provide,  besides  the  ordinary  instruments,  Rongeur 
forceps,  a  mallet  and  chisel,  or  a  trephine.  Carefully  shave  the  half 
of  the  head  corresponding  to  the  traumatism  or,  even  better,  the 
whole  head.  Sterilize  the  field.  Scrub  with  soap  and  water,  fol- 
lowed by  ether,  which  in  turn  is  followed  by  bichloride  solution. 
There  must  be  no  relaxation  in  the  disinfection,  whether  exploration 
is  to  be  extensive  or  not,  for  asepsis  is  the  best  means  of  preventing 
a  hernia  of  the  brain. 

General  Anesthesia. — -Often  the  sensibility  is  so  benumbed,  the 
patient  so  depressed,  that  anesthesia  is  both  unnecessary  and  danger- 
ous. Chloroform  is  generally  best  for  brain  surgery,  but  ether  is 
safer  in  these  urgent  cases  with  much  shock. 


512 


URGENT   craniectomy:   TREPHINING 


Incision. — The  incision  will  vary  with  the  conditions.  We  will 
suppose  three  circumstances:  (a)  there  is  an  extensive  skin  wound; 
(b)  there  is  a  bullet  wound;  (c)  there  is  no  wound  of  the  soft  parts. 

(a)  If  there  is  an  extensive  and  ragged  skin  wound,  it  is  better  to 
enlarge  it  at  once  by  crucial  incision.  This  has  the  advantage  of 
being  rapidly  done,  but  has  the  disadvantage  that  it  interferes  with 
the  blood  supply  of  the  flaps  (Fig.  384). 


Fig.  384. — Depressed  fracture  of  the  skull.     Crucial  incision.     {Veau.) 

(b)  If  there  is  a  bullet  wound,  make  a  ''V-shaped flap  with  the 
bullet  wound  in  the  center,  and  which  retains  its  attachment  below, 
the  better  to  conserve  the  blood  supply. 

(c)  If  there  is  no  open  wound,  make  the  same  sort  of  ''U  "-shaped 
flap  with  its  pedicle  downward,  over  the  site  of  the  contusion. 

Cut  boldly  to  the  bone  if  it  is  resistant.  If  the  fragments  are 
mobile  under  the  scalp,  proceed  cautiously,  but  do  not  stop  until  on 
the  pericranium.  The  incision  will  often  traverse  a  zone  which  is 
contused  and  infiltrated,  the  various  layers  being  indistinguishable. 

If  possible,  form  the  flaps  first  and  then  catch  the  bleeding  points 


TREPHINING 


513 


along  the  edges  of  the  flaps.  In  some  cases  it  may  be  necessary  to 
clamp  a  vessel  before  the  incisions  are  completed. 

As  soon  as  the  bone  is  reached,  hurriedly  strip  back  the  flaps,  in- 
cluding the  periosteum.  The  site  of  the  fracture  is  now  exposed 
(Fig.  385).  One  of  two  conditions  presents:  (i)  there  are  depressed 
fragments  which  must  be  removed,  or  (2)  there  is  di  fissure  without  de- 
pression, but  beneath  the  bone  there  is  a  clot  to  remove  and  a  hemor- 
rhage to  check. 

(i)  The  fragments  are  often  superimposed  in  two  layers  and  those 
of  the  internal  table  are  usually  the  most  extensive.     In  some  cases 


Fig.  385. — Stripping  back  the  peiiosteum  to  expose  the  field  of  fracture.     {Veau.) 


the  fragments  are  easily  extracted,  but  in  others  the  bony  fragments 
are  so  wedged  in  that  it  is  difficult  to  induce  any  instrument  to  pry 
them  loose.  Failing  in  this,  notch  the  sound  bone  along  the  line  of 
fracture  with  the  chisel,  and  in  this  manner  open  up  a  way  to  intro- 
duce the  elevator.  Be  careful  not  to  further  bruise  the  brain  in 
extracting  the  fragments,  employing  only  horizontal  traction. 
Never  wrench  or  twist  the  fragments  (Fig.  386). 

The  deeper  fragments  are  usually  adherent  to  the  dura  mater  and, 
if  so,  require  to  be  stripped  loose  before  attempting  extraction. 

(2)  If  there  exists  merely  di  fissure,  it  will  be  necessary  to  trephine. 
2>3 


514 


URGENT  craniectomy:  TREPHINING 


At  the  possible  site  of  the  hemorrhage,  create  an  orifice  in  the  skull, 
either  with  the  trephine  or  with  mallet  and  chisel. 

Trephine. — (A)  The  ordinary  Gait  trephine  may  be  employed. 
Begin  by  protruding  its  sharp  point  about  1/16  inch  and  boring  it 
into  the  skull  at  the  selected  site.  As  soon  as  the  cutting  edge  of  the 
trephine  has  grooved  the  skull,  retract  the  point,  and  proceed  to 
deepen  the  groove  by  rapid  half-rotations  of  the  wrist.  From  time 
to  time,  test  the  groove  with  the  point  of  a  probe  to  be  sure  that  one 


Fig.  386. — Removal  of  the  fragments.     {Veau.) 

side  is  not  cutting  faster  than  the  other.  If  there  is  any  difference, 
regulate  the  pressure  accordingly.  Diminished  resistance  and 
increased  blood  flow  indicate  penetration  of  the  outer  table. 

The  inner  table  is  more  resistant,  and,  when  it  is  reached,  one  must 
proceed  more  cautiously.  When  it  is  judged  that  section  is  com- 
plete, the  trephine  may  be  removed  and  gentle  effort  made  to  elevate 
the  button.  If  the  bone  is  completely  divided,  the  button  is  easily 
removed. 

(B)  Doyens'  instrument  is  in  less  common  use,  but  is  simple  and 
efficient.  It  consists  of  a  brace,  a  perforator,  and  burrs  of  various 
sizes  (Fig.  387). 

Begin  by  attaching  the  perforator  and  drilUng  a  shallow  hole. 


DOYEN   TREPHINE 


515 


steadying  the  brace  with  the  left  hand.  The  instrument  must  always 
be  kept  perpendicular  to  the  skull.  Next  replace  the  perforator  with 
a  burr  and  rapidly  ream  out  the  opening  begun  by  the  perforator.  As 
before,  one  recognizes  the  approach  to  the  diploe  and  the  inner  table. 


Fig.  387. — Doyen  trephine.  The  perforator  attached  to  the  brace  is  used  to  cut  through 
the  outer  table;  the  opening  subsequently  enlarged  by  burrs  of  various  sizes,  replacing  the 
perforator  on  the  brace. 


The  burr  pushes  the  dura  before  it  without  injury  (Fig.  388).  A 
quadrilateral  or  circular  flap  may  be  outlined  by  additional  openings, 
and  the  chisel  or  rongeur  used  to  complete  the  section  of  the  flap. 

(C)  The  mallet  and  chisel  may  be  used  and,  while  not  so  efficient 
as  the  trephine,  will  serve  the  purpose.  Begin 
by  cutting  a  narrow  groove  in  the  skull,  deep- 
ening it  gradually  until  the  inner  table  is 
reached  and  divided.  The  chief  point  to  be 
emphasized  is  that  the  chisel  is  to  be  held 
quite  obliquely  to  avoid  concussion  and  un- 
expected penetration. 

Detach  the  dura  mater.  Whatever  the  means 
employed,  the  dura  is  now  exposed,  and  if  the 
opening,  which  should  have  a  diameter  of  at  least  2  inches,  needs 
to  be  enlarged,  the  dura  should  be  detached  from  the  edge  of 
bone  and  the  chisel  or  rongeur  employed.  Enlarge  so  as  to  ex- 
pose as  much  as  possible  of  the  middle  meningeal  artery. 

Treat  the  hemorrhage.     Once  the  cranial  cavity  is  well  exposed,  the 


Fig.  388 — Doyen  tre- 
phine; showing  manner  in 
which  the  burr  approaches 
the  dura. 


5i6 


URGENT   craniectomy:    TREPHINING 


next  concern  is  the  hemorrhage,     (a)  There  is  a  clot  to  be  removed; 
(b)  a  bleeding  vessel  to  control. 

(a)  The  clot  may  be  removed  with  the  finger  or  with  a  dull  curette. 
The  amount  of  the  accumulated  blood  may  be  astonishing,  but  one 
must  work  patiently.  The  clot  must  be  removed  to  the  last  particle, 
remembering  that  toward  the  base  there  is  the  greatest  abundance. 
The  white  and  resistant  dura  mater  must  be  exposed  in  every  direc- 
tion (Fig.  389). 

(b)  Next  look  for  the  bleeding  vessel.  A  jet  of  blood  may  indicate 
the  proper  point  at  once,  and  the  vessel  is  caught  with  forceps  and  a 


Fig.  389. — Removal  of  the  clot.     (Veau.) 

ligature  passed  with  a  needle  (Fig.  390).  If  the  bleeding  point  is  too 
deep,  the  forceps  may  be  left  in  position  for  twenty-four  hours. 
More  often,  perhaps,  the  source  of  the  hemorrhage  cannot  be  defi- 
nitely determined  and  as  soon  as  the  compress  is  removed,  the  blood 
wells  up  from  the  bottom  of  the  cavity.  Depressing  the  head,  the 
change  in  the  stream's  direction  may  reveal  its  source  which  is  liable 
to  be  the  middle  meningeal  vein;  it  is  to  be  caught  up  and  ligated 
like  the  artery.  If  the  blood  comes  from  a  sinus,  pack  the  cavity 
with  sterile  gauze.  The  hemostasis  must  be  complete.  If  there  is 
only  shght,  yet  persistent  oozing,  leave  a  gauze  tampon  for  twenty- 


AFTER   TREATMENT 


517 


four   hours.     Suture   the  angles  of  the   wound   and   apply   a   dry 
dressing. 

Another  case,  more  rare:  The  dura  fnater  is  lacerated  and  the  brain, 
more  or  less  contused,  is  exposed.  Catch  the  edges  of  the  dural 
wound  with  forceps  and,  raising  the  membrane,  gently  wipe  out  the 
clots  with  sterile  gauze. 

A  mere  slit  in  the  dura  may  be  repaired  by  catgut  suture,  but  if 
there  is  loss  of  tissue,  it  is  useless  to  attempt  suture  of  this  inelastic 
membrane.  The  hemorrhage  must  be  cared  for  in  the  manner 
already  described. 


Fig.  390. — Ligation  of  the  middle  meningeal  artery.     (Veau.) 


Most  trying  are  those  cases  presenting  a  subdural  hematoma.  Tre- 
phining is  completed  and  the  dura  is  exposed,  but  there  is  no  clot. 
Instead,  the  dura,  tense  and  darkened,  bulges  toward  the  orifice. 
Make  a  crucial  incision  in  the  dura,  or  raise  a  flap  with  its  base  above, 
and  wipe  out  the  exudate,  usually  diffused.  Be  very  careful  not  to 
give  additional  injury  to  the  contused  brain  tissue.  Leave  a  strip  of 
sterile  gauze  in  the  wound  for  drainage,  removing  it  on  the  second 
day. 

After-treatment. — -Following  the  operation,  it  may  be  necessary 
to  inject  i  or  2  quarts  of  salt  solution  in  the  first  thirty-six 
hours.     No  alcoholic  stimulants  must  be  used.     Keep  the  patient 


5i8  URGENT  craniectomy:  trephining 

absolutely  quiet,  the  head  slightly  elevated,  and  change  the  dressing 
as  often  as  soiled.  If  sepsis  occurs,  open  up  the  wound.  If  there  is 
hernia  cerebri,  Treves  advises  a  gauze  pad  saturated  with  alcohol 
held  on  under  light  pressure. 

Results. — -The  patient  may  die  without  regaining  consciousness, 
owing  to  the  shock  of  the  traumatism,  aggra  ated  perhaps  by  that 
of  the  operation;  for  this  reason,  it  is  absolutely  necessary  to  give 
as  little  chloroform  and  to  do  the  operation  as  rapidly  as  possible. 

He  may  die  the  next  day  from  persistent  hemorrhage.  He  may 
die  between  the  third  and  eighth  day  from  septic  meningitis,  due  to 
infection  from  the  injury  or  the  operation.  Watch  the  course  of  the 
temperature  in  order  to  forecast  sepsis. 

Finally,  he  may  recover,  and  even  then  he  may  develop  a  Jack- 
sonian  epilepsy,  delayed  perhaps  as  long  as  ten  years.  ^ 

tracture  of  the  base  of  the  skull 

It  has  already  been  said  it  would  seem  that  the  only  way,  as  cer- 
tainly as  may  be,  to  forestall  infection  in  fracture  of  the  base  is  to 
trephine  and  drain,  leaving  a  permanent  escape  for  microbes  and 
their  toxins.  If  there  is  evidence  of  compression  originating  at  the 
base,  the  trephining  is  even  more  imperative. 

Gushing  recommends  drainage  through  the  lower  temporal  region 
for  the  reason  that  very  much  more  frequently  the  middle  fossa  is 
involved,  the  middle  meningeal  artery  ruptured,  and  the  tip  of  the 
middle  cerebral  lobe  contused. 

Operation. — Make  an  incision  from  the  middle  of  the  zygoma  di- 
rectly upward  to  the  temporal  ridge.  Clamp  the  divided  branches  of 
the  artery.  Divide  the  temporal  fascia  and  split  the  muscle  in  the 
same  hne  and  cut  through  to  the  bone.  Strip  back  the  two  halves 
of  the  temporal  by  free  use  of  the  rugine.  If  there  is  a  line  of  fracture, 
or  some  indication  of  pressure,  trephine  accordingly.  Otherwise,  aim 
to  make  the  opening  near  the  junction  of  the  temporal  with  the  great 
wing  of  the  sphenoid.     An  extradural  hemorrhage  may  be  brought 

^  It  occasionally  happens  that  the  hemorrhage  occurs  on  the  side  opposite 
the  traumatism.  There  is  nothing  to  do  but  repeat  the  trephining  on  the  op- 
posite side,  for  the  matter  cannot  be  determined  beforehand. 


TREPHINING    THE  BASE  519 

to  light  and  a  ruptured  middle  meningeal  found.  In  other  cases,  the 
effusion  will  be  reached  only  after  the  dura  is  divided.  The  escape 
of  the  bloody  cerebrospinal  fluid  will  be  favored  by  passing  a  curved 
blunt  dissector  down  under  the  temporal  lobe.  If  the  effusion  is 
merely  serous,  the  wound  may  be  closed;  if  there  is  any  persistence  of 
oozing,  a  strip  of  rubber  tissue  should  be  left  in  the  lower  angle  of  the 
wound,  extending  into  the  cranial  cavity  under  the  temporal  lobe. 
Vincent  (Revue  de  Chirurgie,  Aug.,  1909)  concludes  that  this  inter- 
vention will  reduce  materially  the  sequelae  so  common  to  fracture  of 
the  base  not  treated  by  operation.  But  with  this  conclusion  the 
majority  of  surgeons  do  not  agree  and  the  tendency  is  to  treat  these 
cases  by  non-operative  methods.  Certainly  for  the  general  prac- 
titioner operative  procedures  will  remain  a  method  only  to  be  em- 
ployed when  focal  signs  of  brain  pressure  are  present. 

TREPHINING    THE   SUBOCCIPITAL   REGION 

A  case  of  Ford's  illustrates  this  procedure:  A  man  of  fifty  years 
fell  from  a  street-car,  striking  upon  his  head.  He  was  only  slightly 
dazed;  insisted  he  was  not  hurt  and  walked  home.  An  hour  later, 
his  head  began  to  pain  severely  and  in  the  course  of  a  couple  of  hours 
he  began  to  grow  drowsy  and  so  gradually  lapsed  into  unconscious- 
ness. He  developed  a  divergent  strabismus,  but  his  pupils  re- 
mained normal  and  there  were  no  signs  of  motor  paralysis.  There 
were  no  marks  about  his  head  to  indicate  injury. 

After  twenty-four  hours,  Ford  was  called  in.  He  found  the  pa- 
tient still  unconscious  and  with  the  pulse  and  respiration  of  com- 
pression. He  was  removed  to  the  hospital  for  operation.  After  the 
head  was  shaved,  a  flatness  was  noticed  below  the  occipital  protuber- 
ance, though  there  was  no  depression  or  evidence  of  contusion.  It 
was  decided,  however,  to  trephine  over  this  point.  A  semilunar 
incision,  convex  upward,  mapped  out  a  flap  with  the  base  downward, 
and  the  skull  was  exposed.  A  stellated  non-depressed  fracture  was 
found.  A  trephine  button  removed  revealed  the  presence  of  a  large 
clot.  A  large  area  of  bone  was  removed  with  rongeur  forceps  and  an 
immense  subdural  clot  cleaned  out  of  the  posterior  fossa.  A  strip 
of  iodoform  gauze  was  left  for  drainage.     Uninterrupted  recovery. 


52 O  URGENT   CRANIECTOMY:   TREPHINING 

We  might  add  that  in  all  cases  of  head  injury  followed  by  compres- 
sion symptoms,  but  in  which  there  is  no  evidence  of  rupture  of  the 
middle  meningeal  artery  nor  any  focal  symptom,  the  suboccipital 
operation  is  preferable  to  the  subtemporal.  It  will  give  easier  and 
safer  access  and  more  efficient  drainage. 

TREPHINING  THE  FRONTAL  REGION 

A  case  reported  by  Axtell,  of  Bellingham,  Wash.  (Northwest 
Medicine,  Nov.,  1908),  illustrates  the  procedure: 

A  laborer  received  a  violent  blow  from  a  cable  hook  above  the  left 
eye.  In  spite  of  the  severity  of  the  injury,  the  man  walked  a  mile  to 
camp.  Traveling  by  a  logging  train,  by  boat,  and  by  street  car, 
nine  hours  later  he  reached  the  hospital,  showing  no  indication  of 
collapse  till  he  reached  his  destination.  He  had  a  marked  depres- 
sion over  the  left  orbit,  a  swollen  eyelid,  and  a  protruding  eyeball. 

A  semicircular  incision  extending  from  the  bridge  of  the  nose  to  the 
external  angular  process  exposed  the  shattered  supraorbital  ridge. 
The  orbital  plate  of  the  frontal  bone  was  broken  into  fragments  and 
a  large  blood  clot  was  found  filling  the  upper  and  back  portion  of  the 
socket,  forcing  the  eye  onto  the  cheek. 

Three  lines  of  fracture  extended  from  the  supra-orbital  ridge  across 
the  frontal,  which  was  depressed  in  several  places.  The  fragments 
of  the  orbital  plate  were  removed;  and,  on  removing  the  depressed 
portions  of  the  frontal,  the  dura  mater  and  subjacent  portion  of  the 
brain  were  found  mangled.  The  brain  tissue  was  trimmed  out,  the 
dura  adjusted,  and  the  fragment  of  the  supra-orbital  ridge  that 
remained  attached  to  the  pericranium  was  so  turned  and  fastened 
that  it  covered  the  supra-orbital  ridge  that  had  been  destroyed. 
This  was  retained  in  place  by  sutures  passed  through  the  skin  flap 
which  was  drawn  into  place.  The  recovery  was  uninterrupted,  and 
a  year  after  there  was  nothing  to  indicate  the  injury  but  a  puffiness 
of  the  upper  lid. 

Trephining  for  Gunshot  Wounds. — Every  case  of  gunshot  wound 
of  the  skull  must  be  explored;  though,  of  course,  no  trephining  is 
necessary  unless  there  is  perforation  of  the  skull  or  unless  there^are 
evidences  of  gunshot  fracture  without  perforation. 


TREPHINING   FOR    GUNSHOT  52 1 

When  it  has  been  determined  that  there  is  perforation,  raise  a  flap 
of  the  scalp  with  the  bullet  wound  in  the  center,  as  has  been  already 
described.  The  flap  must  be  larger  than  the  possible  trephine  open- 
ing in  the  skull.  Enlarge  the  opening  in  the  skull  with  trephine, 
chisel  and  mallet,  or  with  rongeur  forceps.  Remove  all  fragments  of 
bone  and  foreign  matter,  wipe  out  the  dural  and  cerebral  wounds  with 
sterile  gauze.  Be  patient  and  persistent  in  this  cleansing.  Do  not 
explore  the  bullet  track  or  attempt  to  remove  the  bullet  unless,  of 
course,  it  is  within  easy  reach.  A  case  operated  by  the  author  illus- 
trates the  matter. 

A  countryman  was  shot  in  the  top  of  the  head  with  a  38  revolver 
by  a  circus  employee,  the  outcome  of  a  drunken  brawl.  He  was 
carted  home  to  die  but  after  forty-eight  hours  he  was  still  alive  and 
surgical  aid  was  called.  He  had  never  regained  consciousness  and 
he  had  the  pulse  and  respiration  of  compression.  His  kitchen  was 
converted  into  an  operating  room  and  the  skull  trephined.  The 
bullet  ranged  from  the  center  of  the  vault  through  the  brain  to  the 
base.  Through  the  ragged  hole  in  the  brain  the  bullet  could  be  felt 
and  was  removed  only  to  be  followed  by  serious  hemorrhage,  con- 
trolled by  packing  with  a  long  strip  of  iodoform  gauze  which  was 
brought  out  through  the  bullet  opening  in  the  skin  flap  in  the 
course  of  repair. 

In  an  hour  after  the  operation  the  patient  was  conscious,  his  pulse 
and  respiration  much  improved.  In  a  few  hours,  however,  he  grew 
restless,  and  his  temperature  and  pulse  rate  began  to  rise  and  at 
the  end  of  twenty-four  hours  he  was  in  active  delirium. 

The  gauze  packing  was  removed  followed  almost  immediately  by 
improvement.  There  was  only  slight  oozing  from  the  wound  which 
proceeded  to  repair  without  the  least  sign  of  infection. 

The  man's  recovery  was  rapid  and  apparently  complete,  except 
that  for  some  time  he  had  slight  disturbance  of  sight  due  possibly 
to  some  traumatism  of  the  visual  centers  in  the  occipital  lobes. 


CHAPTER  V 

MASTOID  ABSCESS 

The  tympanum,  and  likewise  its  accessory  cavities,  are  normally 
sterile,  but  there  are  two  highways  by  which  infection  may  reach 
this  site;  the  Eustachian  tube,  and  the  external  auditory  canal.  The 
Eustachian  canal  is  the  much  more  common  route,  the  infection  first 
gaining  a  foothold  in  the  mucous  membrane  of  the  naso-pharynx, 
so  that  an  inflammation  of  the  mucosa  of  the  middle  ear  is  often  only 
a  step  further  in  the  ordinary  pharyngeal  catarrhal  process. 

Finally,  the  catarrhal'  inflammation  may  become  a  purulent  one, 
in  either  case,  running  an  acute  or  chronic  course.  Again,  the  pyo- 
genic germ  may  not  long  limit  its  operation  to  the  tympanum;  but 
eventually  invades  the  pneumatic  spaces  adjacent,  the  antrum  and 
mastoid  cells;  and  then  there  may  develop  a  mastoid  abscess,  a  con- 
dition full  of  potential  danger.  The  thin  roof  of  the  middle  ear  is  the 
dividing  line  between  the  posterior  and  middle  cerebral  fossae,  and 
through  it,  infection  may  reach  the  cerebellum  or  the  middle  lobe 
of  the  cerebrum.  ^Meningitis,  epidural,  cerebral,  or  cerebellar  abscess 
is  the  immediate  result. 

The  mastoid  cells  are  separated  from  the  lateral  sinus  by  a  bony 
partition,  so  that  through  the  small  venous  channels  or  by  necrosis 
of  the  bony  wall,  infection  may  reach  the  sinus.  Finally,  general 
infection  and  sinus  thrombosis  may  ensue,  followed  perhaps  by 
metastatic  abscess. 

These  are  the  actual  dangers  of  mastoid  abscess  and  one  can  never 
tell  how  fast  the  pathological  process  may  extend,  aided  by  bone  ero- 
sion or  by  the  escape  of  the  infectious  matter  through  apertures  in 
the  bone  or  by  way  of  the  blood  vessels  and  lymphatics. 

Acute  puruhnt  mastoiditis,  then,  is  an  emergency,  and  every  doctor 
should  feel  himseh  prepared  to  trephine  the  mastoid  if  it  beomes  his 
duty,  and  it  is  his  duty  if  no  one  more  skilled  is  at  hand. 

How  shall  one  recognize  this  emergency? 

522 


PARACENTESIS    •  523 

The  pain,  sleeplessness,  prostration,  fever,  together  with  the  his- 
tory of  the  case,  point  with  a  great  degree  of  probability  to  the  nature 
of  the  trouble.  Now,  if  the  examination  adds  certain  other  signs  to 
these  symptoms,  the  indications  for  intervention  are  definite: 

(i)  You  find  the  upper  and  posterior  quadrant  of  the  ear  drum 
(Shrapnell's  membrane)  bulging  and  perhaps  the  superior  and  poste- 
rior walls  of  the  canal  are  swollen. 

(2)  You  find  persistent  tenderness  over  the  mastoid  process. 

(3)  You  may  observe  that  a  previously  free  discharge  has  suddenly 
diminished  and  this  is  an  added  warning  that  delay  is  dangerous. 

To  repeat,  the  cardinal  symptoms  are  pain,  redness,  swell- 
ing, bulging  of  the  drum,  and  fever.  The  first  thing  to  do  is  a  para- 
centesis. 

PARACENTESIS 

Douche  the  auditory  canal  gently  with  warm,  sterile  water;  co- 
cainize the  canal  with  a  lo  per  cent,  solution  and  wait  five  or  ten 
minutes.  With  the  otoscope,  expose  the  drum  and  locate  the  bulging 
area.  Puncture  it  with  a  small  pointed  bistoury  making  an  incision 
3  or  4  mm.  long,  downward  and  forward. 

There  is  nothing  to  fear.  Even  if  the  drum  has  spontaneously 
ruptured,  it  is  often  an  advantage  to  enlarge  the  opening.  Usually 
a  few  drops  of  pus  escape.     Follow  with  irrigation. 

If,  at  the  end  of  twenty-four  hours,  the  symptoms  have  not  sub- 
sided, proceed  without  further  delay  to  trephine  the  mastoid. 

OPERATION   FOR   MASTOID   ABSCESS 

The  operation  is  easy  and  without  much  danger  if  one  but  knows 
the  anatomy  (Fig.  395).  The  sigmoid  sinus  is  more  shallow  in  chil- 
dren than  adults.  Recall  the  situation  of  the  spine  of  Henle,  the 
facial  nerve,  and  the  lateral  sinus.  The  spine  of  Henle  marks 
the  upper  limit  of  the  external  meatus;  J^  inch  above  it  is  the 
middle  cerebral  fossa;  the  mastoid  antrum  is   J^  inch   posterior. 

Shave  the  temporo-parietal  region  and  scrupulously  prepare  the 
field.     General  anesthesia  is  indispensable. 

Special  instruments  necessary  are  a  Macewen  seeker,  a  chisel  (i 


524 


MASTOID   ABSCESS 


/    I. 


Fig    391. — Landmarks  of  the  mastoid.     The  square  represents  the  area  to  be  trephined; 
the  dotted  lines,  the  course  of  the  lateral  sinus.     (V'eaw.) 


Fig.  392. — Incision  for  mastoid  operation.     {V eau.) 


TREPHINING   THE   MASTOID 


525 


cm.    wide),    a    small    gouge,    mallet,    curette,    curved    periosteal 
elevator,  and  probe. 

Incision  (Fig.  392). — Begin  at  the  apex  of  the  mastoid  and  follow 
the  curve  of  the  external  ear  to  the  level  of  its  attachment  above. 
This  incision  reaches  to  the  bone;  and,  when  operating  on  children, 
be  careful  not  to  cut  through  the  bone.  Catch  the  bleeding  vessels 
in  the  gaping  wound.     Rapidly  denude  the  bone,  an  undertak- 


FiG.  393. — Denuding  the  mastoid  with  the  rugine.     {Veau.) 


ing  somewhat  difficult  below  where  the  sterno-mastoid  is  attached 

(Fig.  393)- 

Introduce  a  sound  into  the  external  auditory  canal  to  determine 
its  direction.     Expose  the  spine  of  Henle. 

Trephine.  Start  the  chisel  vertically  5  mm.  behind  the 
meatus;  two  or  three  slight  blows  of  the  mallet  will  be  sufficient. 
In  a  child,  a  bistoury  may  be  used.  Make  the  second  trace  with  the 
chisel  horizontal  and  on  a  level  with  the  spine  of  Henle.  The  third 
is  parallel  with  the  second,  and  finally  the  fourth,  parallel  with  the 
first,  completes  the  outline  of  chip.     This  fourth  line  of  section  is 


526 


MASTOID   ABSCESS 


in  the  danger  area,  nearly  over  the  lateral  sinus.  In  making  it,  hold 
the  chisel  obliquely  instead  of  vertically  as  in  the  first  (Fig.  394).  By 
slight  and  rapid  blows,  remove  this  chip. 


Fig.  394-— Outlining  the  chip  to  be  removed.     (Veau.) 


Fig.  395. — Exposing  the  lower  mastoid  cells.     (Veau.) 

If  this  does  not  expose  the  cells,  deepen  the  opening  carefully  with 
the  gouge.  Pus  will  often  be  found  at  the  first  incision  into  the  bony 
wall. 


INJURY   TO   THE    LATERAL   SINUS 


527 


Introduce  a  seeker  or  blunt  probe,  which  will  locate  the  various 
cavities  and  canals  leading  to  the  cells  of  the  mastoid  and  antrum. 
Their  coverings  are  then  chipped  off,  or  they  may  be  merely  curetted. 

Chisel  below  first  (Fig.  395),  and  then,  with  the  guide,  locate  the 
posterior  limit  of  the  cells  and  chisel  off  the  bone  lying  over  the  point 
of  the  guide.  A  trough  may  be  trephined  downward  toward  the  tip. 
Remember  that  posteriorly  there  is  the  lateral  sinus  (Fig.  396).  Do 
not  stop  until  all  the  cells  are  freely  exposed. 


Fig.  396. — Exposing  the  posterior  cells.     The  lateral  sinus   must  be  avoided.     (Veau.) 


When  the  mastoid  cells  are  thus  opened  up,  it  remains  to  expose 
the  antrum  (Fig.  397).  It  lies  in  the  direction  upward  and  forward 
at  what  seems  a  considerable  depth,  i  to  3  cm.  Locate  the 
cavity  with  the  guide,  and  enlarge  freely.  The  mastoid  cells  and 
the  antrum  are  now  a  single  cavity.  Carefully  curette  the  necrosed 
bone  and  fungosities,  but  be  very  careful  when  curetting  over  the 
posterior  wall,  for  the  lateral  sinus  may  be  exposed.  Throughout 
the  operation,  one  may  be  disturbed  by  the  hemorrhage,  always  con- 
siderable, and  it  will  be  necessary  to  sponge  continually,  for  it  is  in- 
dispensable that  one  see  what  he  is  doing. 

Certain  accidents  may  occur  in  the  course  of  the  operation. 

(i)  The  lateral  sinus  may  be  wounded,  immediately  recognized 
by  the  excessive  hemorrhage;  but  do  not  be  perturbed,  for  it  is  easy 


528 


MASTOID   ABSCESS 


to  arrest  the  bleeding.  Pack  the  point  or  apply  hot  moist  applica- 
tions with  sterile  gauze  and  continue  the  operation.  If  you  find 
thrombosis,  it  will  be  necessary  to  open  the  sinus. 

(2)  The  cranial  cavity  may  be  opened,  but  neither  is  this  particu- 
larly serious.  However,  you  should  avoid,  if  possible,  an  injury 
to  the  meninges,  for  there  is  danger  of  infection.  Chisel  discreetly, 
therefore,  at  the  upper  angle  of  the  opening. 

If  you  do  wound  the  dura,  disinfect  and  tampon,  but  do  not 
attempt  suture.  It  is  scarcely  possible  at  that  depth  in  a  cavity  so 
narrow. 


Fig.  397- — The  operation  completed,  the  guide  is  in  the  antrum.      (Veau.) 

The  facial  nerve  may  get  in  the  way,  and  if  wounded,  that  is  indeed 
a  serious  matter,  for  you  can  do  nothing  to  remedy  it.  It  is  deeply 
situated  and  if  you  follow  the  guide,  you  are  scarcely  likely  to  reach  it 
with  the  gouge.  It  is  almost  certain  to  be  injured  if  the  mastoid  is 
fractured  in  the  course  of  the  trephining,  and  this  will  happen  if  the 
mallet  and  chisel  are  recklessly  used.  Injury  to  the  facial  nerve  is 
really  the  one  danger  of  the  operation.  Close  approach  is  indicated 
by  twitching  of  the  facial  muscles,  and  for  this  the  anesthetist  should 
be  instructed  to  watch  while  you  are  working  in  the  nerve  zone. 

Dressing  and  Subsequent  Treatment. — Partially  suture  the  wound 
and  pack  with  iodoform  gauze.  The  dressings  are  as  important  as  the 
operation.     If  neglected,  a  fistula  may  form  or  the  suppuration  may 


POST- OPERATIVE   TREATMENT  529 

recur.  Instruct  the  patient  that  repair  may  require  six  to  eight 
weeks,  or  longer. 

On  the  second  day  after  the  operation,  remove  the  gauze  and  irri- 
gate with  warm  sterile  water,  dry  carefully  and  repack  methodically 
so  that  all  the  diverticula  are  filled.  They  must  not  be  allowed  to  close 
over.     Granulation  from  the  bottom  is  indispensable. 

Change  the  dressing  every  other  day.  Repress  excessive  granula- 
tion with  tincture  of  iodine  or  nitrate  of  silver. 

Keep  the  patient  in  bed  for  one  week;  keep  the  bowels  open,  and 
regulate  the  diet. 


34 


CHAPTER  \1 

GENERAL  TECHNIC  OF  LAPAROTOMY 

Since  so  many  urgent  conditions  require  a  laparotomy,  every  doc- 
tor should  be  familiar  with  the  general  technic  of  the  procedure  with- 
out regard  to  any  particular  purpose  for  which  the  abdomen  may  be 
opened. 

For  the  purpose  of  ready  review,  the  various  difficulties  and  their 
management  and  the  after-treatment  are  briefly  outhned. 

Preparation  of  the  Patient. — WTienever  possible,  the  patient  should 
be  under  a  preHminar}'  treatment  for  two  or  three  days  in  order  that 
the  bowels  may  be  thoroughly  cleansed,  the  field  of  operation  ster- 
iUzed  ■\;\4th  certainty,  and  the  functions  of  the  organs  noted.  In 
emergency  work,  these  details  cannot,  of  course,  be  so  definitely 
regulated,  but  to  omit  any  of  them  is  a  handicap. 

To  have  the  bowels  emptied  by  castor  oil  and  enemata  is  the  best 
prophylaxis  against  meteorism,  which  may  be  a  source  of  embarrass- 
ment to  the  operator  in  the  course  of  the  operation,  and  a  source  of 
discomfort  and  perhaps  danger  to  the  patient  subsequently. 

However  urgent  the  operation  may  be,  the  sterilization  of  the  field 
must  be  definite,  even  though  the  methods  be  abbre\'iated.  To 
scrub  with  soap  and  water,  shave,  wash  wnth  alcohol  or  ether  to 
remove  the  oils,  and  finally  bathe  with  bichloride  solution  and  cover 
with  bichloride  compresses  until  ready  to  make  the  incision  is  to 
realize  a  practical  asepsis  so  far  as  the  skin  is  concerned;  or  the  ster- 
ilization may  be  even  more  rapidly  accomplished  by  washing,  the 
skin  with  alcohol  and  ether,  shaving  and  drjdng;  and  then  painting 
with  tincture  of  iodine. 

To  have  a  definite  knowledge  of  the  patient's  temperament,  of  the 
action  of  his  circulation  and  respiratory  organs  and  of  his  kidneys 
is  to  forestall  many  difficulties  and  dangers.  At  least,  a  full  stomach 
should  be  washed  out,  and  the  bladder  emptied  before  the  operation  is 

530 


TECHNIC    OF   LAPAROTOMY  53 1 

begun.  After  the  skin  is  prepared  and  before  the  incision  is  made, 
the  field  is  covered  with  sterile  towels  and  the  whole  body  with  a 
sterile  sheet,  split  over  the  site  of  the  proposed  incision.  Small 
towel  clamps  may  be  used  in  fastening  the  towels  to  the  skin. 

Incision. — ^The  operator  may  stand  on  either  side.  It  is  preferable 
to  stand  to  the  patient's  right  and  cut  from  above  toward  the  pubes, 
supposing  a  median  laparotomy. 

The  skin  and  subcutaneous  fatty  tissues  are  divided  first.  Clamp 
the  small  vessels  and  gently  sponge.  In  the  case  of  abscess  and 
chronic  inflammation,  the  bleeding  is  likely  to  be  rather  free  but 
never  dangerous. 

The  aponeurosis,  when  possible,  should  be  divided  in  the  linea  alba, 
because  the  bleeding  will  be  less  and  the  access  to  the  peritoneum 
readier.  If  made  on  either  side  of  the  middle  line,  the  incision  opens 
into  the  sheath  of  the  rectus,  whose  inner  border  should  be  displaced 
to  the  outer  side  or  its  fibers  split.  The  edges  of  this  fascia  should  be 
caught  with  forceps  in  order  to  be  more  readily  recognized  in  the 
course  of  repair. 

The  peritoneum  is  now  exposed,  covered  usually  by  fatty  areolar 
tissue,  more  or  less  thick  and  which  may  confuse  the  novice,  but  it  is 
to  be  cut  through  without  fear  until  the  peritoneum  itself  appears. 
Catch  up  a  fold  of  it  between  two  forceps  and  make  a  small  opening 
with  either  knife  or  scissors,  using  caution  not  to  cut  into  the  bowel 
or  omentum. 

The  lips  of  the  peritoneal  wound  are  controlled  with  forceps  which 
are  to  be  left  attached;  and  now  enlarge  the  opening  in  either  direc- 
tion, using  the  finger  as  a  guide  and  as  a  protection  to  the  bowel. 
Approaching  the  pubes,  guard  against  wounding  the  bladder,  of  which 
there  is  no  danger  if  it  has  been  previously  emptied.  In  any  event,  it 
can  be  readily  located  by  the  sense  of  touch. 

Protect  the  Cut  Surfaces. — -When  the  peritoneum  is  opened  to  the 
necessary  extent,  apply  two  wide  compresses  of  gauze,  so  as  to  com- 
pletely cover  the  incisions  and  attached  forceps,  tucking  the  edge  of 
each  compress  under  either  side  of  the  peritoneum.  This  is  to 
diminish  the  chances  of  infection  and  to  prevent  bruising  the 
peritoneum. 

In  like  manner,  and  for  the  same  purpose,  the  parts  that  are  to  be 


532  GENERAL   TECHNIC    OF   LAPAROTOMY 

dealt  with  are  packed  off  from  adjacent  structures  with  large  com- 
presses which  are  not  only  more  efficient  than  small  ones,  but  also  are 
less  likely  to  be  lost  within  the  peritoneal  cavity.  The  surgeon  or  a 
responsible  assistant  must  always  know  how  many  compresses 
are  brought  into  use,  and  they  must  be  accounted  for  before  the 
cavity  is  closed.  It  is  remarkable  how  easily  a  large  compress  may 
be  lost  to  sight  in  the  abdominal  cavity.  It  is  an  added  precaution 
to  have  a  tape  sewed  to  each  compress,  to  which  a  forceps  is  apphed 
after  the  compress  is  placed. 

The  aim  is  completely  to  isolate  the  part  operated  on,  and  once  this 
packing  is  complete  the  compresses  are  not  to  be  removed  until  the 
operation  is  finished.  If  infection  is  present  it  is  well  to  have  two  or 
three  layers  of  compresses  so  that  the  soiled  ones  may  be  removed 
without  the  bowel  being  allowed  to  project  into  the  field.  In  pelvic 
operations  the  Trendelenburg  position  is  of  great  advantage,  per- 
mitting the  bowel  the  more  readily  to  be  displaced  and  packed  off. 

Managemejit  of  Peritoneal  Adhesions. — The  novice  and  even  the 
most  practised  surgeon  may  experience  the  greatest  difficulty  in  sepa- 
rating adherent  organs,  their  peritoneal  surfaces  glued  together  as 
the  result  of  inflammation. 

In  the  case  of  recent  adhesions,  they  are  soft  and  easily  broken. 
In  other  cases,  they  consist  of  bands  w^hich  need  only  be  divided 
with  scissors;  but  finally  they  may  bind  together  large  areas  of  adja- 
cent structures  so  as  often  to  render  them  indistinguishable. 

Even  here  with  a  Uttle  patience  one  may  often  find  a  plane  of 
cleavage,  especially  if  the  parietal  peritoneum  is  involved.  If  the 
organ  cannot  be  separated  from  the  parietal  peritoneum,  a  segment 
of  this  latter  is  to  be  cut  out  and  left  attached  to  the  viscus  concerned. 
In  the  case  of  the  omentum  it  is  to  be  ligated  twice  and  cut  between. 
In  the  case  of  the  intestine,  the  greatest  care  must  be  used  not  to 
break  through  its  wall. 

In  general,  intestinal  adhesions  discovered  in  the  course  of  opera- 
tion are  not  to  be  broken  up  except  as  they  interfere  with  the  work  in 
hand  or  are  likely  to  obstruct  the  bowel. 

If  no  plane  of  cleavage  can  be  found,  then  the  other  organ  involved 
must  be  deprived  of  its  peritoneal  coat  to  protect  the  gut.  If  the  sur- 
face of  the  intestinal  loop  is  left  raw  after  the  separation,  the  Lembert 


DRAINAGE  AFTER  LAPAROTOMY  533 

suture  should  be  employed.  If  the  bowel  wall  is  torn  through,  it 
must  be  repaired  by  two  rows  of  suture,  a  through-and-through  and 
a  Lembert  suture. 

Hemorrhage.— The  visceral  blood  supply  is  complex;  to  have  its 
anatomy  clearly  in  mind  is  a  great  advantage  in  the  case  of  hemor- 
rhage from  larger  vessels.  To  locate  the  vessel  at  fault,  to  clamp  it 
and  ligate  quickly,  speeds  the  operation.  Capillary  oozing  can 
generally  be  controlled  by  a  few  moments'  appHcation  of  hot  com- 
presses. A  compress  wet  with  alcohol  will  often  promptly  check  free 
bleeding.  If  the  oozing  is  persistent  at  the  end  of  the  operation  and 
measures  applied  have  failed  to  check  it,  the  abdomen  must  not  be 
closed  without  drainage. 

To  insure  against  recurrence  of  hemorrhage  as  well  as  to  prevent 
infection  and  adhesions,  all  raw  surfaces  should  be  covered  over  with 
a  peritoneal  coat.  It  is  never  desirable  and  seldom  necessary  to 
leave  a  denuded  area  in  the  peritoneal  cavity.  Use  of  the  Lembert 
suture  and  of  the  free  omentum  enables  one  to  obliterate  them. 
Such  as  must  be  left  should  be  sprinkled  with  aristol. 

Drainage. — The  old  dictum,  "When  in  doubt,  drain,"  does  not 
apply  with  such  force  to  laparotomy  as  formerly.  In  fact,  there  are 
those  bold  enough  to  say,  ''When  in  doubt  do  not  drain."  Still  it 
must  be  admitted  that,  in  spite  of  drawbacks,  drainage  is  a  real 
safeguard  against  infection.  One  should  drain,  then,  when  any  sep- 
tic process  is  present  or  is  likely  to  develop,  as  in  the  case  of  per- 
forating wounds  of  the  intestine. 

Drainage  must  be  employed  whenever  it  is  impossible  to  control 
bleeding  from  raw  surfaces.  If  there  is  no  infective  process  present 
in  the  peritoneal  cavity,  if  there  is  no  obvious  reason  for  any  to 
develop  later,  the  abdomen  is  to  be  closed  completely. 

The  preferable  method  of  draining  the  abdominal  cavity  is  by 
rubber  tubes.  This  is  the  only  method  available  if  pus  is  present. 
If  the  main  object  is  to  get  rid  of  blood,  then  the  tube  should  contain 
a  wick  of  gauze  which  should  rest  upon  the  oozing  surface  that  it  may 
serve  the  double  purpose  of  hemostasis  and  drainage. 

As  soon  as  the  oozing  has  ceased  the  gauze  wick  is  to  be  withdrawn 
and  usually  it  is  ineffective  after  twenty-four  hours.  The  removal 
of  gauze  drains  is  often  difficult  and  the  traction  must  be  gentle. 


534 


GENERAL  TECHNIC  OF  LAPAROTOMY 


The  tubal  drains  are  to  be  removed  as  soon  as  the  danger  of  sepsis 
is  passed,  which  is  usually  after  the  third  day.  If  at  this  time 
infection  has  developed  the  tube  is  withdrawn,  sterilized,  and  replaced 
and  so  on  daily  thereafter  until  the  suppuration  is  under  control.  It 
is  in  these  cases  that  Balsam  Peru  is  of  service  in  checking  the  pus 
formation. 

Repair  of  the  Abdominal  Wall. — ^Suppose  the  operation  complete. 
The  final  inspection  of  ligatures  and  sutures  is  made,  the  cavity  is 


Fig.  398. — Repair  of  the  abdo- 
minal wall.  Peritoneum  sutured. 
Continuous  suture  of  recti  and  fas- 
cia begun.      {Guibe.) 


Fig.  399. — Fascia  repaired.  In- 
terrupted skin  sutures  placed,  ready 
to  tie. 


wiped  out,  the  compresses  are  removed  and  counted,  the  vessels  in 
the  abdominal  wall  that  were  clamped  are  ligated,  if  necessary,  and 
repair  of  the  abdominal  wall  is  begun. 

The  peritoneum,  to  which  the  forceps  still  remain  attached,  is 
pulled  up  into  view.  If  the  Trendelenburg  position  has  been  used, 
the  table  is  now  brought  to  the  horizontal;  the  intestines  are  brought 
back  into  place,  the  omentum  spread  out  over  them,  and  a  compress 
appHed  to  protect  the  bowel  while  the  peritoneum  is  repaired  with  a 


POST-OPERATIVE   TREATMENT 


535 


continuous  No.  i  catgut  suture.  The  compress  is  withdrawn  before 
the  last  two  or  three  stitches  are  passed. 

The  aponeurosis  and  muscles  are  now  repaired  with  continuous 
chromic  gut  suture  (Fig.  398). 

The  skin,  finally,  is  to  be  repaired  with  interrupted  silkworm-gut 
sutures,  passing  some  of  them  deep  enough  to  include  the  muscles  and 
aponeurosis  so  as  to  obliterate  any  dead  spaces.  If  coaptation  is 
not  perfect,  a  few  superficial  catgut  sutures  may  be  used  as  necessary. 
One  may  close  the  skin  simply  by  the  continuous  catgut  or  chromic 
gut  suture  or,  as  many  prefer,  by  the  subcuticular  stitch  (Fig.  399). 

Of  course,  if  drainage  has  been  employed,  the  closure  cannot  be 
complete,  though  the  suturing  is  to  be  carried  close  up  to  the  tube. 
In  case  great  haste  is  required,  the  abdomen  may  be  closed  by 
through-and-through  sutures  of  silkworm-gut. 

After-treatment. — 'In  the  uncomplicated  case,  the  after-treatment  is 
simple.  The  patient  is  put  to  bed  with  hot-water  bottles  at  his  feet 
and  provision  made  for  proper  ventilation.  Fresh  air  is  of  the  utmost 
importance.  As  he  recovers  from  the  anesthetic,  he  is  given  water 
cautiously  for  the  first  twenty-four  hours.  After  that,  liquid  nour- 
ishment should  be  given  in  small  quantities  at  frequent  intervals. 
The  bowels  should  be  moved  on  the  second  day  by  a  light  soapsuds 
enema. 

It  is  rare,  however,  that  these  patients  do  not  have  some  complica- 
tion. If  there  was  much  shock  or  much  hemorrhage,  or  if  the  anes- 
thesia was  prolonged,  give  normal  solution  by  one  of  the  three 
methods,  hot  coffee  by  the  rectum  and  whatever  cardiac  stimulant 
may  seem  indicated,  strychnia,  brandy,  or  camphorated  oil. 

If  the  pain  is  severe,  small  doses  of  morphine  hypodermically  should 
be  given  until  the  patient  is  comfortable. 

If  there  is  much  nausea,  try  a  glass  of  warm  soda-water  which  will 
probably  be  thrown  up,  and  thus  washes  out  the  stomach.  If  the 
nausea  is  quite  severe,  wash  out  the  stomach  and  put  the  patient  in  a 
half-sitting  position.  If  the  thirst  is  extreme  along  with  vomiting, 
enemas  of  normal  salt  solution  give  the  most  relief. 

Sometimes  5-15  minims  of  aromatic  spirits  of  ammonia,  given 
hypodermically,  tend  to  relieve  the  nausea,  while  acting  as  a  diffusi- 
ble stimulant. 


536  GENERAL   TECHNIC    OE   LAPAROTOMY 

If  there  is  much  flatulence  or  meteorism,  give  minute  doses  of  calo- 
mel and  empty  the  bowel  with  soapsuds  enema.  If  this  does  not 
give  reUef,  the  enema  consisting  of  2  ounces  of  Epsom  salts  and 
glycerin  and  i  ounce  of  turpentine  may  be  employed. 

Acute  dilatation  of  the  stomach  must  be  watched  for.  If  discovered 
at  once  and  properly  treated  it  is  not  a  serious  complication.  Other- 
wise it  may  be  a  large  factor  in  determining  a  fatality. 

Gastric  lavage  with  alkahne  solutions,  followed  by  small  doses  of 
calomel,  usually  speedily  controls  this  compUcation. 

A  special  line  of  treatment  is  required  if  post-operative  ileus  develops 
(see  page  586). 


CHAPTER  VII 
LAPAROTOMY  FOR  TRAUMATISM 

The  indications  for  laparotomy  following  traumatism  are  as  follows : 

1.  Perforating  gunshot  wounds. 

2.  Perforating  stab  wounds  likely  to  have  wounded  a  viscus. 

3.  Contusions  of  the  abdomen  presenting  symptoms  of  dangerous 
lesions  of  abdominal  viscera  or  vessels;  not  always  definite,  but 
operate  at  once  if  you  find  these  appearances  following  contusions: 

(a)  The  abdominal  walls  are  resistant  some  distance  from  the  in- 
jury; a  progressive  meteorism  reaching  the  hepatic  region;  dullness 
over  the  iliac  fossae  or  the  flanks,  indicating  hemorrhage. 

(b)  The  pulse  is  weak  and  rapid,  and  growing  worse. 

(c)  The  general  condition  of  the  patient  is  alarming,  pallor,  pain, 
excitement  or  delirium,  subnormal  temperature. 

But  whether  it  be  an  open  wound  or  a  contusion,  do  not  wait  for 
the  symptoms  of  peritonitis,  for  it  wall  then  likely  be  too  late.  The 
operation  is  delicate  and  dangerous  in  the  hands  of  the  unskilled, 
and  yet  the  patient's  life  depends  upon  it.  There  is  no  time  to  send 
for  a  specialist  unless  he  is  right  at  hand,  and,  as  Veau  says,  it  is 
better  for  the  patient  to  be  operated  on  early  by  an  inexperienced 
surgeon  than  to  be  operated  on  too  late  by  the  best  surgeon  in  the 
land.  It  is  an  intervention  in  which  one  never  knows  what  he  is 
going  to  find. 

The  steps  of  the  operation  are : 

(i)  A  laparotomy. 

(2)  Search  for  the  hemorrhage  if  there  is  blood  in  the  abdomen. 

(3)  Search  for  visceral  injuries. 

General  anesthesia  is  indispensable,  and  ether  is  preferable  unless 
compelled  to  operate  in  close  quarters  by  lamp  Hght.  Every  pre- 
caution must  be  taken  not  to  aggravate  shock;  the  limbs  should  be 
wrapped  and  the  chest  protected.     The  whole  anterior  abdominal 

537 


538 


LAPAROTOMY   FOR   TRAUMATISM 


wall  must  be  sterilized.     Be  prepared  for  normal  salt  injections, 
often  necessary  throughout  the  operation. 

(i)  Laparotomy.  Whatever  be  the  site  of  the  wound  or  contusion, 
make  an  incision  in  the  middle  Une;  below  the  umbilicus,  usually; 
above,  if  the  injury  points  to  the  epigastrium.  The  incision  at  first 
should  be  about  3  inches  long.  It  will  be  necessary  to  extend 
it  if  the  preliminary  examination  reveals  visceral  injuries.  Divide 
the  skin  and  fatty  tissues  and  catch  up  the  bleeding  vessels.     Look 

for  the  linea  alba,  but  if  not  readily 
found,  go  through  the  muscle;  it  does 
not  greatly  matter.  Divide  the 
transversalis  fascia  and  expose  the 
subperitoneal  fatty  tissue.  It  may 
be  quite  thick. 

The  peritoneum  will  probably  not 
be  recognized  by  its  appearance,  but 
rather  by  observing  the  tissues  gone 
through.  It  is  usually  bulging. 
One  may  be  able  to  see  free  blood 
in  the  cavity  by  reason  of  its  trans- 
^parency. 

Catch  up  the  peritoneum  with 
dissecting  forceps  and  incise  the  cone 
thus  formed,  with  the  cutting-edge 
of  the  scalpel  turned  away  from  the  abdominal  ca\'ity,  that  the 
bowel  may  not  be  wounded  (Fig.  400).  Enlarge  the  small  open- 
ing thus  created,  and  direct  the  assistant  to  seize  the  lips  of  the 
peritoneal  wound  with  forceps. 

Pay  no  attention  to  the  blood  which  may  pour  out,  but  proceed 
rapidly  to  elongate  the  peritoneal  wound  with  the  scissors,  protect- 
ing the  bowel  with  the  left  index  finger  (Fig.  401).  Remember  the 
peritoneum  envelops  the  bladder,  so  do  not  open  the  peritoneum 
down  to  the  pubes,  although  the  skin  wound  should  be  carried  thus 
far  in  order  to  give  the  best  view  (Fig.  402). 

Carefully  catch  up  the  lips  of  the  peritoneal  wound  with  forceps 
which  may  also  serve  as  retractors;  such  control  of  the  peritoneum 
will  also  facihtate  its  suturing  at  the  end  of  the  operation.     It  may 


Fig.  400. — Incising  the  fold  of 
peritoneum.      (Guibe.) 


SOURCES    OF   HEMORRHAGE 


539 


now  be  necessary  to  push  the  anesthesia  a  little  if  there  is  much 
resistance. 

(2)  Locate  afid  check  the  hemorrhage.  Do  not  be  in  a  hurry  to 
put  a  hand  in  the  cavity  but  observe  closely,  sponging  gently.  The 
character  of  the  fluids  may  be  helpful  in  diagnosis.     The  examining 


Fig.  40r. — Enlarging  the  peritoneal  opening  with  the  scissors  on  the  index  finger 

to  guide.      (Cuibe.) 


finger  may  detect  lesions,  or  the  injured  viscera  may  push  up  into 
the  wound. 

The  hemorrhage  may  come  from  the  following:  (a)  omentum; 
(b)  mesentery;  (c)  the  vascular  organs,  liver,  spleen,  kidney;  (d) 
the  vessels  of  the  posterior  abdominal  wall. 

(a)  The  great  omentum  should  be  gently  lifted  out  of  the  cavity. 


540 


LAPAROTOMY   FOR   TRAUMATISM 


It  may  contain  a  hematoma  and  the  divided  vessels  be  hard  to  find. 
Tie  them  with  No.  2  catgut.  If  the  omentum  is  torn  and  lacerated, 
resect  the  injured  portion  (Fig.  410).  It  may  be  split;  the  large 
vessels  opened  must  be  tied;  the  small  will  be  controlled  by  the  con- 
tinuous suture,  which  should  reunite  the  edges  of  the  wound.     If  the 


Fig.  402. — Enlarging  the  opening  toward  the  pubes,  the  bladder  must  not  be 

wounded.      (Guibe.) 

omentum  is  detached  from  the  greater  curvature,  the  stomach  should 
be  exposed,  and  the  omentum  sutured  thereto. 

(b)  The  hemorrhage  from  the  mesentery  may  be  arrested  in  the 
same  manner,  though  one  may  not  find  it  until  in  the  course  of  in- 
specting the  gut.  Mesenteric  wounds  often  exist  without  visceral 
injury.     In  suturing  the  tear,  the  needle  must  be  passed  close  to  the 


WOUNDS   OF   THE  BOWEL  54 1 

edges  of  the  wound  so  that  no  vessel  may  be  wounded  or  included  in 
the  tie. 

If  its  attachment  to  the  bowel  is  disturbed  for,  say,  more  than  3 
inches  or  if  it  is  necessary  to  tie  a  branch  as  large  as  the  radial,  the 
integrity  of  the  corresponding  section  of  gut  is  compromised  and  it 
will  be  advisable  to  resect.  If  unable  to  do  that,  treat  it  as  the 
doubtful  bowel  is  treated  in  strangulated  hernia  (see  page  609). 

(c)  If  the  hemorrhage  proceeds  from  a  wound  of  the  liver,  spleen, 
or  kidney,  tampon  methodically  and  firmly  with  sterile  gauze. 

If  the  liver  is  ruptured  extensively  and  tamponade  has  no  effect, 
try  deep  suturing.  If  this  does  not  succeed,  the  wound  is  probably 
beyond  surgical  aid. 

If  the  spleen  is  extensively  lacerated,  remove  it  (see  page  549). 

(d)  If  the  vessels  of  the  posterior  abdominal  wall  are  involved  or 
the  splenic,  mesenteric,  or  renal,  it  will  often  be  very  difficult  to 
find  the  starting-point  of  the  hemorrhage,  for  it  is  in  the  midst  of  a 
great  clot.  Begin  by  applying  a  large  compress  to  the  suspected 
point  and  make  firm  pressure.  Following  this,  rapidly  wipe  out 
all  the  clots  and  reapply  the  compress.  Raise  its  edge  gradually 
and  as  each  bleeding  point  appears,  clamp  it.  It  will  often  be  im- 
possible to  ligate  at  that  depth  and  forceps  are  left  attached.  The 
forceps  are  to  remain  twenty-four  to  thirty-six  hours.  These  must 
be  removed  without  violence. 

(3)  Wounds  of  the  Intestine:  Do  not  forget  that  intestinal  per- 
forations are  often  multiple,  are  usually  so  after  gunshot  wounds,  so 
that  it  is  absolutely  necessary  to  inspect  the  whole  intestine  that  no 
wound  may  be  overlooked. 

(A)  Examination  of  the  Bowel. — ^The  procedure  must  be  methodical. 
Do  not  pick  up  first  one  segment  and  then  another  indiscriminately; 
in  this  way  one  part  may  be  examined  several  times  and  another  part 
not  at  all. 

Begin  by  picking  up  with  forceps  any  part  of  the  bowel  that  may 
present;  these  forceps  will  serve  as  a  starting-point  and  landmark. 
It  will  not  hurt  the  bowel  with  its  pressure,  as  it  includes  in  its  hold 
only  the  serous  and  muscular  coats  (Fig.  403). 

Begin  at  this  point,  then,  pulling  up  to  view  segment  after  seg- 
ment, and  as  it  is  inspected,  return  it  to  the  cavity.     The  ma- 


542 


LAPAROTOMY   FOR   TRAUMATISM 


neuver  may  be  attended  with  difficulty  especially  if  one  is  compelled 
to  operate  late,  when  peritonitis  has  begun  and  the  partially  paralyzed 
bowel  is  greatly  distended.  If  several  folds  of  the  bowel  should 
escape  and  there  is  difficulty  in  returning  them,  the  procedure  as 
described  on  page  131  will  be  helpful. 


Fig.  403. — Examining  the  bowel.     (Veau.) 

Begin  by  lifting  up  the  abdominal  wall  by  means  of  the  retractors. 
Cover  the  refractory  mass  with  a  wide  compress  and  then  tuck  each 
border  of  the  compress  into  the  wound,  gradually  working  it  into  the 
abdominal  cavity.  It  will  carry  the  bowel  along.  Then  carefully 
withdraw  the  compress. 

Examining  thus  the  small  intestine,  one  of  its  fixed  points  will 
finally  be  reached,  either  the  cecum  or  the  duodenum;  return  then 
to  the  forceps  and  work  in  the  other  direction.^ 

^  In  the  case  of  gunshot  wounds  penetrating  the  abdomen  from  behind,  the 
difficulties  in  locating  the  injuries  may  be  greatly  increased,  a  fact  illustrated  by 
the  following  case: 

A  colored  man  was  brought  to  the  City  Hospital  with  a  gunshot  wound  in  the 
back,  the  bullet  entering  the  right  lumbar  region  about  2  inches  from  the 
middle  line.  Progressive  abdominal  distention  and  tenderness  with  symptoms 
of  hemorrhage  pointed  to  a  visceral  injury.  He  was  immediately  operated  upon; 
the  abdomen  was  opened  below  the  umbilicus.  The  pelvis  contained  consider- 
able blood,  but  there  was  not  the  quantity  expected.  A  systematic  examination 
of  the  intestine  from  the  cecum  to  the  duodeno-jejunal  juncture  revealed  no  per- 


REPAIR  OF  THE  INTESTINE 


543 


Whenever  a  perforation  is  found,  it  must  be  repaired  before  look- 
ing further. 

(B)  Repair  of  the  Intestinal  Wound. — -When  an  intestinal  wound 
is  located,  seize  its  edges  with  two  forceps,  including  only  the  serous 
and  muscular  coats,  draw  the  part  outside  the  cavity  and  isolate  it 
with  compresses  and  then  suture. 

(a)  Non-perforating  wounds  are  sufficiently  repaired  by  two  or 
three  Lembert  sutures. 

(b)  Small  perforating  wounds,  such  as  bullet  wounds,   must  be 


Fig.  404. — The  inclusive    suture  passed;  tied  and  Lembert  suture  passed;  Lembert  tied. 

repaired  by  suture  in  two  layers  (Fig.  404).  With  fine  silk,  No  i, 
make  a  suture  which  includes  all  three  coats,  serous,  muscular  and 
mucous  (Fig.  405).  If  the  wound  is  longer  than  two-thirds  of  an 
inch  use  two  such  sutures,  etc.  These  sutures  are  to  be  covered  in 
and  buried  by  the  second  layer,  which  involves  only  the  serous  coat 
(Lembert  suture).      In  introducing  them,  begin  at  least   J^  inch 

foration.  No  opening  in  the  posterior  abdominal  wall  could  be  found  below  the 
level  of  the  umbilicus.  The  incision  was  extended  and  the  examining  finger 
located  a  tear  behind  the  stomach.  At  this  time  the  patient's  condition  grew  so 
bad  it  was  necessary  to  cease  the  search  and  before  the  abdomen  could  be  com- 
pletely closed,  he  died. 

The  post-mortem  revealed  a  long  tear  In  the  transverse  portion  of  the  duodenum. 
The  bullet  had  struck  the  transverse  process  of  a  lumbar  vertebra,  had  deflected 
to  the  left,  wounding  the  ascending  vena  cava  and  the  duodenum,  and  had  lodged 
in  the  anterior  abdominal  wall.  The  blood  escaping  from  the  vena  cava  had  not 
emptied  into  the  abdomen,  but  had  followed  the  vein  along  the  spine  and  had 
flooded  the  posterior  mediastinum. 


544 


L.\PAROTOMY  POR  TRAUMATISM 


back  of  the  first  line  and  use  either  a  continuous  or  interrupted  suture 
(Fig.  406). 

(c)  Large  Perforating  Wowids. — ^If  the  wound  is  an  incised  one, 


Fig.  406. — The  first  layer  of  sutures 
include  all  coats.     {Veau.) 


Fig.  407 — Applying  sero-serous 
(Lembert)  sutures.     {Veau.) 


suture  without  refreshing  the  edges,  but  if  it  is  contused  or  lacerated 
(Fig.  408)  it  will  be  necessary  for  repair  to  trim  away  to  the  sound 
tissue;  but  take  care  not  to  diminish  the  caliber  of  the  gut. 


yl^ 


Fig.  408. — Trimming  away  the  Fig.  409. — Transverse  suture  to  prevent 

bruised  tissue.     {Veau.)  narrowing  of  the  bowel.     {Veau.) 


As  before,  beginning  at  one  angle,  introduce  the  first  line  of  the 
suture,  including  all  the  coats,  and  using,  if  possible,  a  continuous 
suture  (Fig.  409). 


POST-OPERATIVE   TREATMENT  545 

The  second  line  of  (Lambert  or  sero-serous)  sutures  must  begin 
and  end  J^  inch  beyond  the  limits  of  the  first  and  the  needle  must 
be  entered  far  enough  away  from  the  first  line  that  the  peritoneal 
surfaces  may  be  well  apposed  and  the  first  layer  completely  covered 
(Fig.  410). 

(C)  Resection  of  the  Gut. — If  the  wound  involves  more  than  two- 
thirds  of  the  circumference  or  if  there  is  a  contusion  of  the  whole  or 
a  large  part  of  the  segment,  it  will  be  necessary  to  resect  and  do  a 
circular  enterorrhaphy  or  some  other  form  of 
anastomosis.  If  the  operator  cannot  undertake 
that,  then  the  gut  must  be  treated  as  in  the 
gangrene  of  strangulated  hernia,  making  an 
artificial  anus  (see  page  651).  For  resection  of 
gut,  see  page  609.  ^^ssi^~. 

Drain  the  peritoneal  cavity  with  a  Miculicz 
drain  where  there  is  oozing,  and  with  a  drain- 
age-tube if  infection  is  feared  (see  Chapter  V  on  ^^^  ~^ 

Drainage).  Fig.  410- — ApplyingLem- 

_,,  ,  1    1         •       1  n     1  1  •  f        bert  sutures.    {Veau.) 

Close  the  abdommal  wall  by  three  tiers  of 
suture;  the  peritoneum  with  a  continuous  suture  of  catgut,   the 
muscles  with  chromicized  catgut,  and  the  skin  with  silkworm-gut. 
Apply  a  dry  dressing. 

Subsequent  Care. — Order  complete  rest  and  absence  of  food  for 
forty-eight  hours,  not  even  excepting  milk.  To  quench  the  thirst, 
let  the  patient  suck  a  cloth  saturated  with  water.  It  will  nearly 
always  be  expedient  to  give  salt  solution  either  by  rectum  or  sub- 
cutaneously;  in  the  worst  cases  by  intravenous  infusion. 

Change  the  dressing  the  following  day.  It  will  probably  be  satu- 
rated with  bloody  serum.  On  the  second  day  remove  the  tampons 
and  replace  with  smaller  ones.  On  the  fourth  day  remove  the  drain- 
age-tube, if  employed,  and  replace  with  smaller  one,  which  may  be 
dispensed  with  after  the  eighth  day. 

Prognosis. — The  prognosis  will  depend  upon  the  extent  of  the 
injuries  and  the  skill  of  the  operator. 

Death  may  occur  from  hemorrhage  or  peritonitis  shortly  after  the 
operation,  or  about  the  eighth  or  tenth  day  if  the  suturing  has  been 
imperfectly  done. 
35 


546  LAPAROTOMY   FOR   TRAUMATISM 

Fecal  abscess  and  fecal  fistula  may  result,  requiring  a  later  opera- 
tion, or  which  may  eventually  cure  themselves. 

Complete  recovery  happily  very  often  occurs  and  would  be  the  rule 
if  the  doctor  had  the  judgment  or  authority  to  operate  within  the 
first  few  hours  after  the  traumatism. 

WOUNDS  OF  THE  STOMACH 

If  the  injury  involves  the  upper  pole  of  the  abdomen,  the  stomach 
must  be  examined  carefully.  Extensive  injuries  are  often  overlooked. 
An  escape  of  gas  and  bleeding  may  point  to  the  situation  of  the  lesion. 

Pick  up  the  stomach  with  gauze  to  get  a  firmer  hold,  and  examine 
the  anterior  surface  systematically.  Repair  any  wounds,  as  in  the 
intestine,  by  two  rows  of  suture;  the  one  including  all  the  coats,  the 
other  only  the  serous  and  muscular. 

In  the  case  of  gunshot  wounds,  examine  the  posterior  surface.  To 
reach  the  posterior  surface,  Auvray  insists  upon  a  large  incision  in 
the  gastro-colic  omentum  along  the  lower  border  of  the  stomach, 
for  a  large  incision  facilitates  examination  and  does  not  compromise 
the  vitaUty  of  any  structure.  If  even  then  one  cannot  gain  full 
access,  he  advises  an  exploratory  gastrotomy  (Revue  de  Chirurgie, 
Nov.  10,  1906). 

The  posterior  surface  may  be  reached  another  way,  by  turning 
up  the  transverse  colon  and  opening  the  transverse  meso-colon.  To 
prevent  the  spread  of  fluids  which  may  escape  from  the  stomach 
the  field  must  be  carefully  walled  off  with  compresses  as  the  explora- 
tion proceeds.  If  the  wound  can  be  felt  but  is  impossible  to  be  seen, 
then  no  attempt  must  be  made  to  suture,  but  the  cavity  is  to  be 
thoroughly  drained. 

If  there  has  been  much  loss  of  substance,  it  may  be  necessary  to  do 
a  gastro-enterostomy. 

WOUNDS  OF  THE  LIVER 

If  the  nature  of  the  abdominal  injury  leaves  no  doubt  that  the 
liver  is  wounded,  it  may  be  advisable  to  vary  the  procedure  as  al- 
ready described.  A  support  under  the  back  tilts  the  abdomen  so 
that  the  intestine  drops  down  toward  the  pelvic  cavity,  and  at  the 
same  time  the  liver  is  bulged  forward  and  made  more  accessible. 


REPAIR    OF    THE    LIVER 


547 


The  incision  beginning  at  the  ensiform  cartilage  may  follow  the 
costal  arch,  dividing,  if  necessary,  the  right  rectus  muscle.  It  may 
even  be  necessary,  in  order  to  reach  the  upper  surface  of  the  liver, 
to  resect  the  tenth,  ninth,  or  eighth  rib. 

You  mav  find  on  examination  of  the  viscera  that  the  liver  has  been 


Fig.  411. — Suture  of  the  liver.     {Moynihan.) 


contused,  and  there  is  evidently  a  hematoma  formed  beneath  the  cap- 
sule. It  is  better  not  to  disturb  it  unless  the  conditions  seem  to 
indicate  continuation  of  oozing. 

There  may  be  an  open  wound  of  any  character  or  extent  with  great 
hemorrhage.  One  should  attempt  to  catch  up  and  ligate  the  bleeding 
points,  employing  a  fine  clip  or  artery  forceps.  The  veins,  as  well 
as  the  arteries,  will  stand  the  strain  of  a  ligature,  but  may  need  to  be 


54^  LAPAROTOMY   TOR   TRAUMATISM 

dissected  loose  from  the  liver  substance  before  the  ligature  can  be 
applied. 

If  the  patient  is  not  too  weak,  attempt  repair  by  suture.  It  is  a 
little  difficult,  but  quite  possible  and  certainly  desirable. 

Employ  a  blunt-pointed  needle  and  do  not  push  it  through  boldly, 
but  slowly,  and  as  you  push,  gently  oscillate  the  needle.  In  this 
manner,  the  point  may  slip  by  the  vessels.  Employ  a  large  catgut 
suture,  as  a  fine  suture  cuts  through  the  soft  tissue  (Fig.  411). 

Van  Buren  Knott  (Iowa  Med.  Journal,  Oct.,  1907)  recommends 
inserting  a  strand  of  catgut  parallel  with  the  liver  wound,  tying  the 
ends  of  the  strand  over  small  skeins  of  catgut  to  prevent  tearing. 
Transverse  interrupted  sutures  are  then  passed  so  as  to  include  the 
parallel  sutures  first  passed. 

Failing  to  suture,  there  is  nothing  left  but  the  tamponade,  and  this, 
of  course,  is  the  only  thing  available  in  lacerated  wounds. 

Haynes,  of  New  York  (Annals  of  Surgery,  July,  1907),  describes 
a  case  illustrative  of  some  of  the  difficulties  of  treatment  and  the 
sequelae  of  liver  wounds. 

Patient,  a  man  of  twenty  years,  was  brought  to  the  Harlem  Hos- 
pital with  gunshot  wound  just  below  the  tip  of  the  ensiform  cartilage. 
The  bullet  was  found  to  have  traversed  the  liver  from  before  back- 
ward, and  it  was  necessary  to  get  at  the  wound  of  exit. 

From  the  median  incision,  a  second  incision  was  made  transversely, 
dividing  the  right  rectus  and  the  seventh  and  sixth  costal  cartilages. 
The  falciform  ligament  was  also  divided.  With  strong  traction  upon 
the  costal  arch,  the  posterior  wound  could  be  reached  and  felt  but 
not  seen,  readily  admitting  two  fingers. 

By  the  sense  of  touch,  an  iodoform  wick  was  packed  into  this 
wound  and  a  smaller  one  introduced  into  the  anterior  wound,  and 
both  brought  out  through  the  abdominal  incision.  This  did  not 
entirely  control  the  hemorrhage,  and  so  the  liver  was  forced  up 
against  the  diaphragm  and  held  by  a  large  MicuUcz  tampon  below 
the  liver. 

The  rectus  was  sutured.  The  peritoneum  was  repaired  with  the 
falciform  ligament  included;  the  abdominal  walls  sutured  above  and 
below  the  gauze  wicks. 

On  the  tenth  day  the  tamponade  was  removed;  and  a  few  days 


REPAIR   OF   THE   PANCREAS  549 

later,  the  gauze  wicks,  for  which  rubber  tubes  were  substituted,  a 
discharge  of  bile  and  pus  being  present. 

At  the  end  of  the  third  week  it  became  necessary  to  secure  addi- 
tional drainage,  and  the  ninth  rib  was  resected  in  the  axillary  line, 
where,  in  the  meantime,  the  bullet  had  been  located;  the  costal  and 
phrenic  pleura  were  sutured,  and  the  pleural  cavity  thus  shut  off. 
The  diaphragm  was  opened,  the  pus  drained  out  and  a  long  tube 
passed  from  the  anterior  to  the  posterior  abdominal  wounds,  and  a 
smaller  one  left  in  the  posterior  wound. 

The  progress  of  repair  was  slow  but  sure,  five  months  elapsing 
before  the  cure  was  complete. 

It  should  be  remarked  that  very  rarely  after  gunshot  wounds  of 
the  liver  is  there  notable  external  hemorrhage.  One  must  determine 
the  degree  of  injury  from  the  signs  of  internal  hemorrhage  and  the 
evidences  of  peritoneal  reaction  which  later  develop. 

WOUNDS  OF  THE  PANCREAS 

Do  not  forget  to  examine  the  pancreas  in  wounds  of  the  upper 
zone  of  the  abdomen.  Reach  the  pancreas  from  above  the  stomach, 
opening  through  the  gastro-hepatic  omentum. 

Carefully  mop  out  the  fluids,  blood  and  pancreatic  juice.  Pack 
around  the  site  with  compresses  and  try  to  suture.  Sometimes  two 
or  three  deep  sutures  will  coapt  the  wound  surface  and  completely 
check  the  hemorrhage.  If  the  tail  is  much  crushed,  resect  it  and 
suture  the  stump.  Use  gauze  and  tubal  drainage.  If  the  patient 
does  not  die,  he  may  have  a  subphrenic  abscess  (Figs.  412,  413). 

WOUNDS  OF  THE  SPLEEN 

Any  but  the  slightest  wound  of  the  spleen  is  universally  and  rapidly 
fatal  from  hemorrhage  unless  treated.  One  naturally  thinks  of 
suturing.  If  that  and  tamponade  are  not  effective  to  stop  the 
bleeding,  it  is  indicated  to  try  to  remove  the  viscus.  This  is  not 
difficult  if  there  are  no  adhesions,  though,  if  there  are,  failure  is 
almost  certain.  Under  such  circumstances,  as  Moynihan  suggests, 
the  only  thing  left  is  to  pack  with  gauze,  soaked,  if  necessary,  in 
adrenalin  solution. 


S50 


LAPAROTOMY   FOR   TRAUMATISM 


Noetzel  reviews  his  experience  with  six  cases  in  which  he  removed 
the  spleen  for  injury  and  concludes  that  splenectomy  is  the  only 
safe  way  of  securing  hemostasis.  Suturing  and  tamponing  may 
arrest  bleeding  for  a  time,  but  there  is  danger  that  it  will  return. 

Holliday,  of  Portsmouth,  Virginia,  reports  a  case  illustrating  the 
subject  (Virginia  Medical  Semi-monthly  Journal,  January  ii,  1907); 
patient,  boy,  age  15,  was  struck  in  left  side  by  a  flying  pulley,  frac- 
turing his  arm  in  several  places  and  contusing  the  abdominal  wall. 
His  condition  shortly  became  serious;  temperature  subnormal, 
absolute  dullness  on  the  left  side,  and  marked  rigidity.     Immediate 


Figs.  412  and  413. — Method  of  suture  of  a  wound  in  the  pancreas.  Two  or  three  deep 
sutures  of  stout  catgut  or  silk  are  passed,  and  wound-surfaces  drawn  together.  The  wound- 
edges  are  then  sutured  with  fine  catgut  sutures.      (Moynihan.) 


operation.  The  patient  was  almost  eviscerated  before  the  bleeding 
could  be  located,  but  which  was  finally  found  to  proceed  from  the 
lacerated  external  surface  of  the  spleen;  a  splenectomy  was  quickly 
done,  and  the  abdomen  closed  without  drainage.  Convalescence 
was  easy  and  uneventful. 

Splenectomy. — The  operation  following  rupture  generally  finds 
the  incision  made  in  the  middle  line  on  account  of  the  indications 
for  hemorrhage. 

The  spleen  is  brought  up  into  view  and  delivered  from  the  abdom- 
inal cavity  and  clamped,  avoiding  any  strain  upon  its  pedicle,  for  the 
veins  have  extremely  thin  walls  (Fig.  414). 

Ligate  and  divide  the  pedicle.  Transfix  the  pedicle  with  a  double 
ligature  and  tie  each  half  separately,  and  finally  tie  the  whole  pedicle 
in  a  single  ligature.     If  the  ligament  is  large  and  thick  it  may^be 


SPLENECTOMY 


551 


necessary  to  ligate  it  ''enchaine"  (Fig.  415).  The  pedicle  is  next 
divided,  the  spleen  removed,  and  its  bed  examined  for  any  bleeding 
points.  The  under  surface  of  the  diaphragm  is  very  likely  to  present 
some  oozing. 

Fiske,  of  Brooklyn,  describes  a  case  which  illustrates  the  varia- 
tions in  the  procedure.     (Annals  of  Surgery,  Jan.,  1908.) 

A  man  of  twenty-five  years  was  brought  to  the  Kings  County 
Hospital  with  a  bullet  wound  in  the  left  side  corresponding  to  the 


Fig.  414. — Splenectomy:   Clamps  applied   to   pedicle  preliminary   to   section  along  dotted 

line.      (Cuibe.) 


spleen.  The  symptoms  pointed  to  visceral  injury  and  intra-abdom- 
inal hemorrhage.  An  incision  was  made  over  the  outer  border  of  the 
left  rectus  muscle  from  the  costal  arch  to  a  point  midway  between  the 
umbilicus  and  symphysis.  The  stomach  and  intestine  were  found  to 
be  uninjured.  A  perforation  in  the  transverse  meso-colon  was  re- 
paired, but  the  hemorrhage  continued.  A  transverse  incision  was 
made  and  the'^spleen  examined,  revealing  a  rent  which  admitted  two 
fingers.     The  spleen  was  pulled  up  into  the  wound,  the  pedicle 


552 


LAPAROTOMY  FOR   TRAUMATISM 


clamped  and  ligated  en  fnasse.  After  removing  the  spleen,  the  ves- 
sels were  ligated  separately,  the  abdomen  was  flushed  vdih  saline 
solution,  a  small  gauze  drain  left  in  contact  with  the  stump,  and  the 
wound  closed  with  through-and- through  silkworm-gut  sutures. 
The  temperature  subsequently  did  not  rise  above  ioo°.  The  drain 
was  permanently  removed  on  the  fifth  day.  The  patient  left  the 
hospital  at  the  end  of  the  third  week,  entirely  recovered. 


1  •■  W 

Fig.   415. — Pedicle  of  spleen  ligated  "enchaine".     (jGuibe.) 


WOUNDS  OF  THE  KIDNEY 

If,  while  examining  the  \iscera  in  the  course  of  the  laparotomy, 
you  find  a  ruptured  renal  pelvis  or  a  seriously  lacerated  kidney  bleed- 
ing into  the  peritoneal  cavity,  remove  the  kidney.  ^lake  a  longitu- 
dinal incision  in  its  peritoneal  covering,  strip  the  organ  out  of  its  bed 
and,  lifting  toward  the  surface,  free  the  pedicle. 


REPAIR   OF   THE   KIDNEY  553 

Ligate  the  ureter  first  and  then,  if  possible,  each  of  the  vessels 
separately.  If  the  oozing  persists,  leave  a  Miculicz  drain  or  a  rubber 
tube. 

Intra-peritoneal  rupture  without  injury  to  other  viscera  is  very 
rare. 

Extra-peritoneal  wounds  of  the  kidney  do  not,  as  a  rule,  require 
intervention. 

That  the  kidney  has  been  involved  will  be  suggested  by  pain, 
frequent  micturition,  and  bloody  urine. 

Rest  in  bed,  morphine,  and  limited  diet  are  the  special  indica- 
tions.    An  abdominal  binder  may  give  relief. 

Eliot  (American  Journal  Surgery,  Nov.,  1906)  has  observed  twelve 
cases  of  subcutaneous  rupture  of  the  kidney.  In  seven  cases  there 
was  not  sufficient  extravasation  to  make  a  perceptible  tumor,  and  the 
diagnosis  was  made  by  the  hematuria  and  the  tenderness  over  the 
kidney  and  persistent  rigidity  for  a  number  of  days. 

In  the  remaining  cases  a  well-defined  tumor  appeared  in  the  ilio- 
costal space,  becoming  more  sharply  outlined  as  the  rigidity  dis- 
appeared. In  five  or  six  weeks,  the  tumor  disappeared.  In  no 
instance  was  operation  necessary. 

In  such  cases  of  extra-peritoneal  rupture  as  require  operation,  the 
lumbar  route  should  be  chosen.  Operation  is  indicated  from  the  first 
if  the  violence  was  known  to  be  great  and  a  large  tumor  forms  im- 
mediately. A7t  operation  is  indicated  at  any  time  symptoms  of  sepsis 
appear. 

Morris  Miller  reports  a  case  (Annals  of  Surgery,  Feb.,  1908)  of  a 
man  who  fell,  striking  his  left  side  over  the  lower  rib.  He  felt  faint, 
and  almost  immediately  passed  a  quart  of  blood  by  the  urethra  and 
later  may  clots.  Miller  saw  him  at  the  hospital  an  hour  and  a  half 
later.  There  was  no  shock,  but  the  side  was  rigid  and  tender,  and  an 
indistinct  dull  mass  could  be  felt  in  the  loin.  An  oblique  lumbar 
incision  revealed  an  extensive  rupture  of  the  kidney  with  much 
hemorrhage.  Wicks  of  gauze  were  placed  in  front  and  behind  the 
kidney  and  the  ruptured  segments  pressed  together.  The  patient 
did  well,  the  hemorrhage  gradually  ceased,  though  twice  after  the 
fifth  day  blood  appeared  in  the  urine.  On  the  twelfth  day  the  pack- 
ing was  all  removed,  and  the  opening  finally  healed.     Gibbon,  com- 


554  LAPAROTOMY  FOR  TRAUMATISM 

menting  on  the  case,  remarks  that  hemorrhage  severe  enough  to 
require  operation  does  not  usually  mean  injury  sufficient  to  require 
nephrectomy.  The  question  of  nephrectomy  must  be  decided  when 
the  kidney  is  exposed. 

Stewart  adds  that  the  two  early  indications  for  operation  are  a 
progressively  increasing  hematoma  and  constitutional  symptoms  of 
hemorrhage.  In  several  cases  of  moderate  bleeding  he  had  operated, 
and  afterward  been  sorry  he  had  interfered. 


Fig.  416. — Repair  of  ruptured  bladder.  Applying  through-and-through  sutures.  Sub- 
sequently Lembert  suture  will  be  applied  and  finally  the  parietal  peritoneum  will  be  repaired 
beginning  at  point  of  reflection  onto  the  bladder.    Peritoneum  retained  by  forceps.     (Lejars.) 


WOUNDS  OF  THE  BLADDER 

Wounds  of  the  bladder,  if  not  previously  suspected  from  the  nature 
of  the  abdominal  injuries,  are  inferred  from  the  presence  of  urine  in 
the  peritoneal  cavity.    Sometimes  the  rent  is  hard  to  locate.    Inject 


REPAIR    OF    THE  BLADDER 


555 


the  bladder  with  normal  salt  solution  and  observe  its  mode  of  en- 
trance into  the  peritoneal  cavity. 

The  wound  is  to  be  repaired  by  two  rows  of  sutures,  the  first,  of 
catgut,  involving  all  the  coats  except  the  mucosa;  the  second,  of 
silk,  includes  the  peritoneum  alone  after  the  manner  of  theLembert 
suture.  The  stitches  of  both  rows  must  be  closely  placed  to  seal  the 
wound.  The  result  may  be  tested  by  filling  the  bladder  with  normal 
salt  solution,  and  any  defect  repaired  (Fig.  419). 


Fig.  417. — Van 
Hook's  ureteral  an- 
astomosis. {Binnie.) 


Fig.  418. — Van  Hook's 
ureteral  anastomosis. 
{Binnie.) 


Fig.  419. — Anasto- 
mosis completed. 
{Binnie.) 


A  catheter  should  be  left  in  the  bladder  for  drainage  and  the 
siphonage  kept  up  for  two  or  three  days.  Subsequently,  the  bladder 
should  be  emptied  by  aseptic  catheterization  for  a  few  days  longer. 
The  peritoneum  should  be  drained  for  the  first  forty-eight  hours. 

This  mode  of  treatment  applies  to  the  intra-peritoneal  wounds  of 
the  bladder.  The  extra-peritoneal  wounds  should  be  treated  on  the 
same  principle,  but  often,  under  such  circumstances,  the  operator 
must  be  content  with  suprapubic  drainage  of  the  bladder  until  the 
wound  has  healed. 


5S6  LAPAROTOMY  FOR   TRAUMATISM 

WOUNDS  OF  THE  URETER 

K  it  is  discovered  that  the  ureter  is  wounded  either  by  the  trauma 
or  in  the  course  of  the  operation,  an  effort  should  be  made  at  repair. 
Several  methods  are  available.  If  the  injury  does  not  amount  to 
complete  division,  a  few  perforating  sutures  followed  by  Lembert 
sutures  may  succeed.  Small  wounds  usually  heal  readily,  but  it  is 
safer  to  use  drainage. 

If  the  separation  is  complete,  both  ends  of  the  torn  ureter  may  be 
ligated,  or  the  kidney  may  be  removed,  but  naturally  it  is  preferable, 
if  possible,  to  establish  an  anastomosis.  Under  various  circum- 
stances, the  proximal  end  may  be  anchored  in  the  bladder  or  in  the 
bowel,  or  the  two  ends  may  be  brought  together. 

Van  Hook's  termino-lateral  anastomosis  is  generally  applied. 
The  technic  may  be  briefly  described  in  this  wise: 

Ligate  the  distal  portion  1/4  inch  from  the  end  and  make  a  longi- 
tudinal slit  in  length  double  the  diameter  of  the  tube.  Split  the 
proximal  end  also  for  1/4  inch,  beginning  at  the  free  end. 

Pass  the  sutures.  Employ  a  long  catgut  suture  threaded  on  a 
needle  at  each  end.  One-eighth  inch  from  the  end  of  the  proximal 
portion  of  the  ureter,  pass  the  two  needles  from  without  inward 
(Fig.  417).  Carry  the  two  needles  through  the  split  in  the  distal 
portion,  into  the  lumen  and  let  them  emerge  1/2  inch  below 
the  end  of  the  split  (Fig.  418).  Tighten  the  suture,  which  will  have 
the  effect  of  invaginating  the  upper  segment  in  the  lower  (Fig.  419). 
Around  the  line  of  contact  run  a  Lembert  suture,  and  cover  with 
omentum  or  peritoneum. 


CHAPTER  VIII 

APPENDICITIS.     APPENDICIAL  ABSCESS.     PURULENT 

PERITONITIS^ 

Inflammation  of  the  appendix  presupposes  two  factors,  lowered 
resistance  and  a  pathogenic  germ. 

The  lowered  resistance  of  the  appendicial  tissue  may  find  its 
origin  in  many  diverse  conditions  involving  its  morphology,  anatomy, 
and  physiology.  It  is  generally  agreed  that  it  is  an  organ  undergoing 
a  retrograde  metamorphosis,  or,  at  any  rate,  one  adapting  itself  to 
new  functions. 

There  is  a  small  facility  for  compensatory  circulation  if  its  main 
artery  is  blocked,  and,  in  consequence,  it  is  exposed  to  vicissitudes  of 
nutrition. 

Owing  to  its  varying  position,  it  is  brought  into  contact  and  may 
acquire  connections,  vascular  and  lymphatic,  with  other  abdominal 
and  pelvic  organs  and  structures  and,  by  this  means,  be  the  recipient 
of  pathogenic  bacteria  that  had  not  elsewhere  found  a  favorable  soil. 

The  pathogenic  organisms  which,  under  favorable  conditions,  may 
here  develop  and  produce  various  grades  of  destruction  are  the  bacil- 
lus communis  coli,  the  streptococci,  staphylococci,  and  others  less 
frequent. 

Whatever  part  each  of  these  causative  agents  may  play  in  its  de- 
velopment, the  fact  remains  that  appendicitis  is  one  of  the  frequent 
and  one  of  the  most  dangerous  and  treacherous  diseases  with  which 
the  general  practitioner  has  to  deal. 

Diagnosis. — The  diagnosis  is  not  difficult  in  the  typical  cases, 
but  exceptionally  may  be  extremely  difficult,  or  even  impossible, 
until  the  progress  of  the  symptoms  has  been  observed. 

A  diagnosis  should  never  be  made  from  the  mere  presence  of  what 

1  So  important  is  this  subject  to  the  general  practitioner,  that  he  should  be 
satisfied  to  have  and  study  no  works  less  complete  than  the  classic  volumes  of 
Deaver  or  Kelly. 

557 


558  APPENDICITIS.      PURULENT   PERITONITIS 

are  regarded  as  the  cardinal  symptoms;  not  until  each  symptom  and 
sign  has  been  weighed  and  accorded  its  proper  significance,  and  all 
other  possible  conditions  excluded,  should  it  be  decided  definitely 
that  the  case  is  or  is  not  acute  appendicitis. 

To  discuss  briefly  the  symptoms  upon  which  one  must  rely:  the 
pain  in  the  milder  catarrhal  cases  is  limited  usually  to  the  right  iliac 
fossa.  In  the  ulcerative  type,  with  sudden  onset,  or  the  perforative 
type,  it  is  very  likely  at  first  to  be  general  over  the  abdomen,  but  after 
a  few  hours,  is  rather  definitely  localized  in  the  right  side.  In  the 
gangrenous  cases,  it  may  be  absent  in  one  case  or  severe  in  another, 
depending  upon  the  degree  of  active  peritoneal  inflammation. 

Rigidity  of  the  right  rectus  abdominis  and  pelvic  muscles  is  an 
important  sign,  and  its  degree  is  some  index  to  the  amount  of  perit- 
oneal involvement. 

Gastric  disturbance,  nausea,  and  vomiting  are  fairly  constant  oc- 
currences in  the  first  stages  of  the  attack,  but  last  only  a  short  time. 
T.  B.  Eastman  has  very  strongly  emphasized  the  frequent  connec- 
tion between  the  chronic  forms  of  appendicitis  and  those  appearances 
of  gastric  indigestion  vaguely  grouped  as  "stomach  troubles." 

Constipation  is  almost  the  rule,  and  Kelly  adds  further  that  it  may 
amount  to  an  actual  obstruction.  Only  rarely  does  diarrhea  appear 
with  the  attack,  and  if  it  does,  may  be  regarded  as  indicating  a  grave 
form.  Most  rare  of  all  is  it  for  an  attack  even  of  the  mildest  type, 
to  run  its  course  without  some  aberration  of  bowel  action. 

Tenderness  on  pressure  is  a  symptom  upon  which  alone  the  diag- 
nosis is  too  often  made.  It  is  scarcely  possible  for  it  to  be  wholly 
absent,  and  yet  it  can  by  no  means  be  relied  upon  to  indicate  the 
severity  of  the  attack.  Rosving  states  that  pressure  on  the  left 
McBurney  point  always  elicits  pain  in  appendicitis,  but  not  in  other 
cases. 

Robert  Morris  adds  something  to  this  phase  of  the  diagnosis.  He 
claims  that  tenderness  upon  pressure  over  a  point  opposite  the  um- 
bilicus in  the  line  of  the  anterior  superior  spine  of  the  ilium  has  a 
special  significance  and  is  due  to  involvement  of  the  lumbar  ganglia. 
Thus  Morris'  point  on  the  right  side  will  be  tender  in  appendicitis. 
If  that  point  on  both  sides  is  tender,  the  trouble  is  located  in  the 
pelvis. 


DIAGNOSIS    OF    APPENDICITIS  559 

Tumor. — It  is  folly  to  wait  for  this  sign  to  complete  the  diagnosis, 
for  it  means  the  certainty  of  a  complicated  pathology.  It  means 
peritoneal  involvement  with  plastic  exudates,  or  a  pus  formation,  or 
both. 

Disturbance  of  Pulse  and  Temperature. — There  is  no  other  grave 
disease,  perhaps,  in  which  the  pulse  and  temperature  make  such 
limited  excursions.  The  temperature  in  the  most  serious  cases  may 
not  reach  103°.  Its  elevation  is  in  no  wise  significant.  The  pulse 
in  the  milder  cases  holds  a  certain  ratio  with  the  temperature.  A 
temperature  of  101°,  for  example,  should  be  accompanied  by  a  pulse 
rate  of  90  to  100.  Any  marked  disturbance  of  this  ratio  is  extremely 
significant;  whether  it  is  a  low  temperature  with  a  rapid  pulse  or  a 
high  temperature  with  a  slow  pulse,  the  outlook  is  ominous.  H.  O. 
Panzter,  from  extended  clinical  experience,  insists  that  we  must  rely 
largely  upon  the  rectal  temperature  in  making  a  differential  diagnosis, 
and  that  the  temperature  should  be  invariably  taken  by  both  mouth 
and  rectum.  The  temperature  by  mouth  in  such  cases  may  be  very 
deceptive. 

Such,  very  briefly,  are  the  principal  symptoms  and  signs  which, 
taken  collectively,  must  serve  to  distinguish  the  disorder  from  acute 
intestinal  obstruction,  ovarian  or  tubal  inflammation,  cholecystitis, 
typhoid  fever,  pneumonia,  and  other  acute  diseases. 

There  is  not  much  danger  at  the  present  time,  so  prominently  is  the 
subject  before  the  profession,  that  an  appendicitis  will  be  overlooked. 
Only  too  often  is  an  innocent  appendix  held  to  be  the  cause  of  the 
illness  in  hand.  Lobar  pneumonia,  for  example,  is  likely  to  give  rise 
to  appendicial  symptoms,  and  such  cases  are  likely  to  run  an  atypical 
course. 

It  is  an  appendicitis,  but  what  is  its  character?  Is  it  mild  or 
dangerous?  Is  it  a  simple  catarrhal  trouble  which  will  soon  subside, 
or  is  it  potentially  a  gangrenous  process  with  general  peritonitis 
ahead?  These  are  the  questions  which  confound  the  doctor  and 
upon  their  answer  rest  the  prognosis  and  treatment. 

Four  varieties  are  described  (Fig.  420). 

(i)  Catarrhal  appendicitis,  in  which  the  mucosa  alone  is  involved, 
the  predisposing  causes  are  easily  relieved,  and  the  pathogenic  agent 


56o 


APPENDICITIS.      PURULENT  PERITONITIS 


CNJ 


"H 


Fig.  420. — Types  of  appendicitis  showing  pathological  changes,  i,  Normal  appendix; 
2,  acute  appendicitis;  3,  inflamed  appendix  containing  large  and  small  fecolith;  4, 
Ruptured  gangrenous  appendix  containing  large  fecolith.      (Reed  and  Carnrick.) 


DIAGNOSIS    OF   APPENDICITIS  56 1 

is  of  a  low  order  of  virility.     Neither  local  nor  constitutional  symp- 
toms are  severe,  and  the  attack  very  shortly  subsides. 

(2)  In  the  ulcerative  type  the  process  extends  deeper  and  involves 
the  muscular  and  perhaps  the  serous  coat  to  some  extent  and  there 
is  produced  a  mild  form  of  peritoneal  inflammation.  There  is  usu- 
ally a  diffused  swelling  of  the  whole  appendix. 

(3)  Perforative  appendicitis,  in  which  there  is  local  destruction  of 
all  the  coats  and  communication  with  the  peritoneal  cavity,  is  due  to 
a  sudden  and  virulent  infection  or  an  acute  exacerbation  of  a  slum- 
bering process  and  begins  abruptly  with  intense  pain;  and  in  a  short 
time  ends  in  peritoneal  suppuration,  local  or  general. 

(4)  Gangrenous  Appendicitis. — This  form,  beginning  as  such,  is 
the  most  treacherous,  for  often  the  symptoms  are  in  no  wise  pro- 
portionate to  the  seriousness  of  the  case.  Death  is  impending,  and 
yet  neither  the  pain,  pulse,  nor  temperature  gives  due  warning. 
There  is  absolutely  no  way  at  this  present  time  by  which  the  doctor 
may  recognize  this  condition  de  novo.  It  may  be  imagined  that  such 
a  condition  arises  from  sudden  interference  with  the  blood  current 
to  the  organ,  while  infection  plays  the  lesser  part.  On  the  other  hand, 
gangrene  which  ensues  from  virulent  infection  begins  at  once  with  the 
characteristic  symptoms  of  appendicitis  added  to  those  of  sepsis  and 
peritonitis. 

It  is  from  the  point  of  view  of  these  pathological  variations  that 
the  most  diverse  opinions  as  to  treatment  have  arisen. 

It  is  evident  that  nature,  unaided,  may  be  able  to  take  care  of  the 
milder  type.  It  is  a  clinical  fact  that  nature  by  means  of  her  own, 
may  sometimes  control  and  keep  the  inflammation  within  bounds, 
even  in  the  more  dangerous  cases.  By  means  of  plastic  exudates, 
she  walls  off  and  limits  the  suppurating  area  and  later  provides  a  safe 
means  of  escape  for  the  products  of  suppuration.  But,  unfortu- 
nately, such  a  happy  issue  can  never  be  depended  upon.  On  the 
contrary,  the  suppuration  is  more  likely  to  become  diffuse  and  there 
presents  the  picture  of  purulent  peritonitis  and  the  imminent  prospect 
of  a  fatality.     In  such  a  case  one  loses  sight  of  the  local  symptoms. 

The  abdomen  is  rigid,  tympanitic  and  everywhere  exceedingly 
tender.  The  temperature  is  high ;  the  pulse  rapid ;  the  tongue  coated, 
brown  and  fissured;  and  as  the  disease  progresses,  the  symptoms  of 
36 


562  APPENDICITIS.      PURULENT   PERITONITIS 

circulatory  collapse  appear.  The  temperature  then  becomes  sub- 
normal, the  pulse  almost  uncountable,  and  the  features  pinched  and 
anxious,  until  finally  a  mild  delirium  with  pleasant  hallucinations 
ushers  in  the  end. 

The  infection  may  be  so  severe,  the  toxemia  so  profound,  that  the 
patient  may  die  of  septic  peritonitis  before  pus  has  had  time  to  form. 
Indeed,  death  may  come  from  sepsis  before  the  ordinary  signs  of  in- 
flammation appear. 

Such  may  be  the  outcome  of  what  appears  to  be  the  mildest  case. 
It  is  this  prospect  and  the  attendant  uncertainties  which  have  led 
many  doctors  to  regard  appendicitis  as  an  emergency  to  be  operated 
upon  as  soon  as  the  diagnosis  is  made.  As  Pfaff,  of  Indianapolis, 
puts  it,  the  difference  between  the  mortality  of  i  per  cent,  in  the  very 
early  operations,  and  that  of  15  to  30  per  cent,  in  the  abscess  stage, 
is  so  frightful  that,  in  comparison,  an  occasional  unnecessary  opera- 
tion is  of  no  consequence  at  all.  If  we  are  to  fulfill  our  obligations, 
we  must  act  vigorously  and  to-day. 

This  is  undoubtedly  a  safe  rule  in  the  practice  of  the  skilled  opera- 
tor, who  has  at  his  command  all  the  facilities  of  the  aseptic  operating- 
room  and  trained  assistants. 

The  case  is  quite  different  with  the  general  practitioner,  remote 
from  these  accessories.  Moreover,  it  is  known  that  80  to  85  per 
cent,  of  these  cases  recover  without  operation.  Even  for  the  relaps- 
ing from,  Treves  says  that  much  may  be  done  by  medical  means, 
diet,  attention  to  the  bowels,  and  by  placing  the  patient  under  con- 
ditions more  favorable  to  a  state  of  peace  within  the  abdomen. 

Whatever  may  be  proper  in  hospital  practice,  it  certainly  cannot 
be  imposed  on  the  general  practitioner  that  he  operate  at  once. 
Even  in  connection  with  the  skilled  surgeon,  it  may  be  said  that  his 
technic  has  not  yet  reached  such  a  degree  of  perfection  that  an  opera- 
tion is  always  safer  than  the  milder  form  of  appendicitis  unoperated. 

The  doctor  then  will  face  his  responsibility,  a  heavy  one  truly, 
knowing  there  is  much  to  be  accomplished  by  medical  means  and 
yet  hoping  that  he  will  have  the  judgment  to  recognize  the  failure 
of  nature  and  of  his  art,  and  the  will  to  resort  not  too  late  to  more 
radical  measures. 

Assume  that  the  diagnosis  is  definitely  made;  assume  that  no  sur- 


TREATMENT   OF   APPENDICITIS  563 

geon  is  within  beck  and  call  (for  appendicitis  is  strictly  a  surgical 
disease),  what  will  you  do?  It  is  evident  at  once  that  this  is  a  clin- 
ical hypothesis,  and  the  question  is  to  be  resolved  on  a  clinical  basis. 

I.  You  see  the  case  from  the  first.  The  attack  begins  mildly  or 
with  only  moderate  severity;  there  was  perhaps  a  single  attack  of 
vomiting;  the  pain,  abdominal  tenderness  and  rigidity  are  not 
marked,  and  the  patient's  general  condition  is  good. 

Under  these  circumstances,  as  Lejars  says,  it  is  perfectly  legitimate 
to  institute  a  medical  treatment,  in  the  meantime  holding  the  case 
under  the  strictest  surveillance.  But  this  formula  is  null  without 
the  last  provision.  //  the  march  oj  the  disease  cannot  he  watched,  it  is 
better  to  operate  at  once,  and  this  rule  may  as  well  be  made  to  apply 
to  any  case  in  which  delay  might  otherwise  be  counselled.  You 
decide  to  try  medical  treatment,  but  in  what  form?  Like  many 
others  herein  involved,  the  question  brings  forth  a  varied  response. 

Under  these  circumstances  one  may  follow  the  plan  of  "immobili- 
zation,^' which  Lejars  and  others  so  highly  praise.  But  to  be  effect- 
ive, it  must  be  rigorously  and  consistently  applied. 

Keep  the  patient  absolutely  quiet  in  bed.  Give  no  purgatives — 
and  this  means  give  neither  calomel  nor  oil.  Give  no  enemas.  Sus- 
pend nourishment  absolutely,  relieving  thirst  by  a  few  drops  of  water 
frequently  given. 

Ice  to  the  Abdomen. — 'Not  a  handful  of  ice  in  a  little  bag  applied 
over  the  iliac  fossa,  but  two  or  three  large  bags  covering  the  whole 
abdomen  below  the  umbilicus  and  refilled  as  the  ice  melts. 

Opium,  in  3/5-grain  doses  in  pill  form  every  two  hours  for  an  adult; 
but  it  must  not  be  pushed  to  the  point  of  annulling  all  pain  and  sus- 
pending the  functions  of  the  kidney. 

It  is  far  from  being  the  rule  that  the  practitioner  remote  from  the 
larger  towns  can  have  ice  at  his  command.  Likewise,  opium  in  the 
hands  of  the  inexperienced  may  be  a  two-edged  tool.  He  must  often, 
therefore,  depend  upon  other  modes  of  procedure,  and  for  these, 
there  is  no  lack  of  eminent  authority.  Under  the  circumstances  in- 
dicated, begin  with  a  single  hypodermic  of  morphine  if  the  pain  is 
severe  and  with  small  doses  of  calomel  (Mo~Ko  gr-)  frequently 
repeated,  until  a  grain  or  two  is  taken;  follow  at  the  end  of  three 
hours  with  a  large  dose  of  castor  oil  or  larger  doses  of  albolene  until 


564  APPENDICITIS.      PURULENT   PERITONITIS 

the  bowels  have  moved  freely.  If  the  bowels  are  slow  to  move, 
supplement  the  internal  remedies  with  enemas  of  normal  salt  solution. 
Give  salol  or  carbonate  of  guaiacol  every  three  hours.  Apply  hot 
fomentations  to  the  abdomen,  flannels  wrung  out  of  hot  water  and 
sprinkled  with  turpentine.  Cover  the  hot  flannels  with  several 
additional  thicknesses  and  apply  hot-water  bottles  filled  with  boiling 
water,  and  cover  the  whole  to  retain  the  heat.  As  the  water  cools, 
withdraw,  one  by  one,  the  various  layers  so  that  the  temperature 
may  be  maintained  at  the  highest  point  of  comfort.  Hot  kaolin 
cataplasms  often  render  service. 

As  Oschner  commands,  food  must  be  withheld  absolutely,  and  if 
there  is  much  gastric  disturbance  or  pain,  the  stomach  should  be 
washed  out.  Opium  is  contraindicated  under  this  form  of  treat- 
ment, for  it  is  the  purpose  to  cleanse  the  bowel. 

McGrath,  of  New  York,  probably  expresses  the  prevailing  opinion, 
summing  the  matter  up  in  this  wise  (Medical  Record,  Feb.  i,  1908): 

''Only  in  the  catarrhal  cases  can  there  be  any  question  as  to  treat- 
ment once  the  diagnosis  is  made;  w^hether  it  is  better  to  operate  with- 
out delay  or  seek  to  avail  oneself  of  the  advantage  of  an  interval 
operation.  If  sure  of  the  character  of  the  lesion,  we  may  temporize; 
it  will  do  no  harm  watching  the  patient  carefully  for  any  sign  of 
danger.  Many  of  these  cases  resolve  without  going  on  to  suppura- 
tion or  gangrene,  and  therefore  escape  operation  during  the  acute 
attack.  Nature  may  be  assisted  in  her  efforts  at  spontaneous  cure 
in  these  cases  by  enjoining  complete  rest,  withholding  all  food  and 
permitting  only  water  to  be  taken,  and  by  small  repeated  doses  of 
calomel  and  sodium  bicarbonate.  An  ice-bag  may  be  applied  over 
the  region  of  the  appendix.  But  if  there  is  any  doubt  as  to  the  exact 
pathological  condition,  operation  should  be  advised  unless  marked 
contraindications  exist." 

George  J.  Cook,  of  Indianapolis,  who  has  had  as  much  experience 
with  this  disease  as  anyone  in  the  Mississippi  Valley,  does  not  operate 
in  mild  attacks  of  primary  appendicitis.  If  it  is  a  second  attack,  he 
operates  without  delay.  He  says  that  not  infrequently  a  mild  catar- 
rhal appendicitis  does  not  recur.  In  such  cases,  he  puts  the  patient 
at  rest.  He  unloads  the  bowels  with  enemas  merely.  If  the  attack 
follows  overeating,  he  employs  a  mild  saUne  primarily.     Nothing  but 


TREATMENT   OF   APPENDICITIS  565 

water  is  permitted.  As  an  intestinal  antiseptic,  he  gives  5  grains 
of  carbonate  of  guaiacol  three  or  four  times  in  the  twenty-four  hours. 
If  the  patient  should  complain  much,  he  gives  small  doses  of  opium^ 
after  the  diagnosis  is  made.  He  gives  it  to  quiet  the  pain  and  not  the 
peristalsis,  asserting  that  the  bowel  will  of  itself  be  quiescent  if 
empty.  Ice-bags  applied  to  the  abdomen  as  a  routine  measure  repre- 
sents to  him  the  chief  element  in  the  relief  of  pain  and  control  of 
inflammation. 

Note  that  whatever  the  form  of  treatment,  the  case  must  be  nar- 
rowly watched.  If  the  pulse  and  temperature  remain  in  harmony; 
if  the  abdominal  tension  and  tenderness  tend  to  grow  less;  if  the 
bowels  move  and  gas  escapes  per  rectum;  if  the  general  condition  is 
good;  there  is  ground  to  expect  a  satisfactory  termination,  but  no 
excuse  to  relax  one's  vigilance. 

No  nourishment  should  be  given  by  mouth  until  defervescence  is 
complete,  and  after  that  a  liquid  diet  should  be  maintained  for  one  to 
two  weeks,  depending  upon  the  severity  of  the  attack,  and  rest  in 
bed  as  well.  At  the  end  of  a  few  weeks,  the  appendix  should  be 
removed. 

But  the  progress  of  the  disease  may  suddenly  change.  All  the, 
symptoms  may  become  aggravated  and  the  dangerous  nature  of  the 
case  become  at  once  obvious — immediate  operation  is  indicated; 
or  the  change  may  be  insidious  (unsuspected  by  the  careless  observer) 
and  in  this  instance  the  chief  reliance  must  be  placed  upon  the  pulse. 
If  the  pulse  is  rapid  and  weak  with  a  falling  temperature,  or  if  the 
pulse  falls  to  50  or  60  with  a  rising  temperature;  in  other  words,  if 
there  is  any  marked  divergence  between  pulse  and  temperature, 
again  the  indications  are  to  operate  at  once.  To  repeat,  any  marked 
aggravation  of  the  symptoms  after  improvement  once  begins,  or  the 
occurrence  of  any  marked  disparity  between  pulse  and  temperature, 
however  benign  the  other  symptoms  may  be,  are  indications  for 
operation  without  delay. 

II.  Another  case:  You  have  watched  the  case,  but  the  tempera- 
ture has  persisted,  and  beyond,  say  the  sixth  day,  when  there  should 
be  a  marked  improvement,  you  find  the  temperature  rising  or 
fluctuating,  the  pain  increasing,  a  tumor  forming  most  painful  at  its 
center.     In  this  case  also  the  indication  is  for  immediate  operation. 


566  APPENDICITIS.      PURULENT   PERITONITIS 

III.  Suppose  you  see  the  case  only  at  the  end  of  several  days,  dur- 
ing which  time  the  disease  has  run  a  neglected  course.  May  one  at 
this  time,  with  any  effect,  apply  a  medical  treatment,  or  should  one 
resort  at  once  to  an  operation?  The  question  can  only  be  answered 
after  a  careful  consideration  of  the  history  of  the  case,  such  as  the 
patient  or  his  attendants  can  give,  and  a  thorough  investigation  of 
the  present  symptoms.  Only  when  the  case  is  obviously  benign  can 
one  take  the  responsibiHty  of  further  delay.  For  example,  if  the 
pulse  and  temperature  are  in  accord,  if  the  tenderness  and  tympanites 
are  diminishing,  then  nothing  better  can  be  done  than  to  follow  the 
rules  with  regard  to  rest  and  diet  already  laid  down.  Yet  one  must 
be  ever  mindful  of  the  treacherous  character  of  certain  forms  of 
septic  attack. 

Again,  you  find  the  disease  progressing  and  in  the  active  stage  of 
the  third,  fourth,  or  fifth  day,  \^^th  no  indications  of  beginning  im- 
provement, but  the  symptoms  are  not  aggravated,  and  there  is  a 
plastic  exudate  without  softening:  again  it  may  be  said  that  under 
these  circumstances  it  is  legitimate  to  wait. 

Anv  continuance  of  the  fever  beyond  the  eighth  or  tenth  day,  even 
though  the  pulse  is  good  and  the  exudate  has  not  softened,  is  a  matter 
of  grave  suspicion,  and  with  the  least  enlargement  of  the  tumor  or 
disturbance  of  pulse,  operate  without  delay,  and  it  is  more  than 
likely  you  will  find  a  large  abscess. 

IV.  In  anv  case,  at  any  stage,  if  a  diagnosis  of  abscess  can  be  made 
out — a  palpable  fluctuating  mass,  in  the  iliac  fossa — whatsoever  the 
other  symptoms  may  be,  there  is  but  one  indication,  immediate 
operation.  Xo  practitioner  to  whom  the  task  falls,  whatsoever  his 
ability  or  training,  can  do  anything  else  and  do  his  duty.  Even 
though  vou  cannot  detect  fluctuation,  but  by  vaginal  and  rectal 
examination  determine  that  the  mass  is  doughy  and  painful,  operate 
and  you  will  almost  certainly  find  pus. 

V.  Finally,  even  if  the  case  has  progressed  to  a  general  peritonitis, 
it  is  one's  duty  to  operate  unless  the  patient  be  practically  moribund, 
and  even  in  these  cases,  as  Lejars  puts  it,  operation  has  rescued  a 
certain  number  of  patients  from  the  very  jaws  of  death,  for  without 
operation  they  would  inevitably  have  died. 

Even  though  the  diagnosis  is  not  definitely  established  and  one 


APPENDECTOMY 


567 


considers  the  possibility  of  meeting  with  a  tubercular  peritonitis  or  a 
salpingitis  or  similar  condition,  yet  the  rule  should  be  to  operate  in 
any  case  of  doubt. 

Operation. — Two  operations  will  be  described:  A,  when  no  pus  or 
other  complications  are  expected;  B,  when  pus,  localized  or  diffused, 
is  a  certainty. 


Fig.  421. — Vertical  incision  through  skin,  aponeurosis  and  sheath  of  rectus.     Outer  border 
of  rectus  exposed  in  bottom  of  wound. 


A.  Incision. — ^Begin  i  inch  above  or  2  inches  below  the  line  con- 
necting the  anterior  superior  iliac  spine  with  the  umbilicus.  The 
incision  crosses  this  line  J^  inch  to  its  inner  side  of  its  middle  point 
and  follows,  practically,  the  outer  border  of  the  rectus  abdominis. 


568  APPENDICITIS.      PURULENT   PERITONITIS 

Divide  first  the  skin  and  fat  and  expose  the  aponeurosis  of  the 
external  oblique.  Divide  next  the  aponeurosis  and  under  one  lip  is 
the  edge  of  the  rectus,  and  under  the  other,  the  transversalis  (Fig. 
421).  Split  the  sheath  of  the  rectus  and  retract  the  edge  of  the  rec- 
tus exposing  the  transversalis  fascia. 


Fig.  422. — Rectus    drawn    inward.     Posterior   layer   of   sheath    and   transversalis   fascia 
divided.     Peritoneum  exposed  and  cone  lifted  preparatory  to  dividing. 


Divide  the  transversalis  fascia,  exposing  the  subperitoneal  fat 
and  pick  up  a  fold  of  the  peritoneum,  and  divide  it,  turning  the  cut- 
ting edge  of  the  knife  away  from  the  abdomen  (Fig.  422).  Usually 
the  great  omentum  will  bulge  into  the  wound  after  the  peritoneal 


APPENDECTOMY 


569 


incision  is  enlarged.     Replace  the  omentum  and,  if  necessary,  hold 
it  with  a  gauze  pad. 

Next  introduce  a  finger  and  feel  for  the  cecum,  which  will  be  rec- 
ognized by  its  bands,  and  pull  it  up  into  the  wound  until  the  base 
of  the  appendix  can  be  seen.     The  appendix  may  be  adherent,  and 


Fig.  423. — Appendix  and  part  of  cecum  delivered  and  walled  off  with  gauze. 


the  adhesions  should  be  broken  up  very  gently.  Once  the  appendix 
is  freed,  it  is  to  be  brought  up  out  of  the  wound  and  the  cecum  re- 
turned to  the  abdominal  cavity  and  walled  off  with  gauze  pads 
(Fig.  423). 


570 


APPENDICITIS.      PURULENT   PERITONITIS 


Tie  off  the  meso-appendix  with  catgut,  and  cut  it  away  from  the 
appendix  close  to  its  line  of  attachment. 

An  incision  is  now  carried  around  the  base  of  the  appendix,  divid- 
ing only  the  serous  coat,  which  is  stripped  back  toward  the  cecum, 
forming  a  peritoneal  cuff  (Fig.  424).     The  appendix  is  now  ligated 


J^k. 

M^^%^ 

TK     m      •  mJ^^ 

i>3|^^^^^p5^ 

^^^r^   ^^^U^^n   ^^^^^^^^^^K^^^^^^u         ^^^^^^^B   Ak     ^   ^'^  M 

^%w 

X^y.: 

Fig.   424. — Peritoneal  cuflf  turned  back;  appendix   ligated  and  amputated. 


and  cut  off,  the  mucous  stump  touched  with  carbolic  acid  and  then 
with  alcohol.  The  peritoneal  cuff  is  drawn  over  the  stump  and  su- 
tured. The  stump  is  now  invaginated  and  buried  with  a  row  of 
Lembert  sutures.  The  gauze  pads  are  removed  with  the  exception  of 
one,  which  covers  the  cecum  until  the  last  stitches  are  placed  in  the 


APPENDECTOMY 


571 


peritoneum.  Repair  by  separate  lines  of  suture  the  peritoneum, 
transversalis,  aponeurosis,  and  skin.     Drainage  is  unnecessary. 

B.  The  incision,  4  inches  long,  is  a  finger's  breadth  to  the  inside 
of  the  anterior  superior  iliac  spine,  with  its  middle  corresponding  to 
the  spine  (Fig.  425). 

The  first  incision  traverses  the  skin  and  superficial  fascia,  which 
are  likely  to  be  very  vascular  in  such  a  case.  The  external  oblique 
appears,  its  fibers  parallel  with  the  incision.     Divide  it  the  whole 


'//.. 


1%     _fe.   Il 


/    .# 


£ 


n 


Fig.  425. — Appendicial  incision.     {Veau.)        Fig.  426. — The   external    oblique    divided; 

the   internal   oblique    exposed.      (FeaM.) 


length  of  the  wound  and  catch  the  edges  with  forceps  which  will  serve 
as  retractors  (Fig.  426). 

Next  divide  the  internal  oblique  and  transversalis  muscles,  whose 
fibers  run  transversely.  The  layer  is  thick,  and  several  vessels  will 
need  to  be  caught  (Fig.  427). 

Retract  these  layers  and  the  transversalis  fascia  is  exposed.  This 
you  divide,  bringing  into  view  the  peritoneum. 

Catch  up  a  fold  with  the  forceps,  and  divide  its  base  with  the 
scissors  (Fig.  428).  From  the  small  orifice  thus  created,  there  flows 
a  seropurulent  fluid.  Enlarge  the  peritoneal  opening  and  hold  back 
the  intestine  with  compresses.  Examine  the  cavity.  It  may  be 
that  the  omentum,  thickened  and  infiltrated,  will  cover  the  field, 
but  do  not  disturb  it. 


572 


APPENDICITIS.      PURULENT   PERITONITIS 


Follow  with  the  index  finger  the  wall  of  the  fossa  until  the  cecum 
is  reached.  Wiping  out  the  cavity,  you  may  be  able  to  see  the  bands 
of  the  cecum,  which  are  to  be  followed  downward  by  sight  and  touch, 
for  they  lead  to  the  appendix. 

Remove  the  appendix  if  possible.  You  may  not  be  able  to  find  it, 
but  do  not  prolong  the  search  and  certainly  do  not  break  up  adhesions 
in  this  search. 

When  it  is  located,  gently  draw  it  to  the  surface.  It  is  exceedingly 
friable  and  should  not  be  ruptured.  Throw  a  catgut  ligature  about 
its  base  close  up  to  the  cecum  and  tie  moderately  tight  (Fig.  429). 


Fig.  427. — The  two  oblique  muscles  incised,     Fig.  428. — Showing    the    three    muscular 
the   transversalis  exposed.     {Veau.)  layers  and  the  peritoneum  incised.     {Veau.) 

Amputate  the  appendix,  and  if  there  is  no  bleeding  cut  the  liga- 
ture short.  Determine  now  the  character  of  the  suppuration, 
whether  circumscribed  or  diffuse  (Fig.  430). 

(a)  It  is  Circumscribed. — Wipe  out  the  cavity  very  carefully  with 
sterile  gauze.  Do  not  irrigate.  Place  a  drainage-tube  upward 
toward  the  diaphragm  (Fig.  431).  Do  not  use  violence.  There  a 
new  collection  of  pus  may  be  found.  Pass  a  second  drainage-tube  in 
the  same  manner  down  into  the  pelvic  cavity.  This  is  the  most 
important,  for  the  fluids  tend  to  collect  there.  Leave  the  third  in 
the  iliac  fossa  and  the  fourth  directed  toward  the  middle  of  the 


APPENDECTOMY 


573 


abdomen.  Secure  each  with  a  safety-pin.  Suture  up  to  the 
drainage-tubes,  so  that  the  opening  will  be  only  large  enough  to  ac- 
commodate the  tubes. 

If  the  patient  is  a  female,  after  wiping  out  the  cavity  carefully,  a 
counter-opening  may  be  made  into  the  vagina  in  favorable  cases,  and 
with  efficient  drainage  secured  by  that  route,  the  abdomen  may  be 
completely  closed. 


Fig.  429. — Throwing  a  ligature  around  base  of  sloughing  appendix.     (Veau.) 


In  many  cases  even  without  such  drainage,  the  abdomen  may  be 
closed  after  cleansing  the  cavity,  but  it  cannot  be  advised  in  the 
emergency  work  of  general  practice. 

(b)  The  Suppuration  is  Dijffuse. — Make  a  second  incision  from  the 
umbilicus  downward  for  a  couple  of  inches,  which  is  sufficient. 
When  the  peritoneum  is  opened,  the  fingers  can  touch  through  the 
two  openings. 

If  the  pus  seems  to  have  reached  into  the  left  side,  it  may  be  advis- 
able to  make  a  third  incision  over  the  left  iliac  fossa.  Through  these 
incisions  irrigate  the  abdominal  cavity  with  normal  salt  solution, 
using  plenty,  3  or  4  quarts,  and  continue  the  irrigation  until 
the  fluid  flows  out  clear.  Uifless  it  be  complete,  reaching  every  part 
of  the  cavity,  irrigation  had  better  be  dispensed  with.     The  addi- 


574 


.AJPPENDICITIS.      PURULENT   PERITONITIS 


tional  incisions  may  even  be  unnecessary  if  the  following  treatment  is 
pursued: 

The  patient  is  now  put  in  the  Fowler  position  and  a  continuous  rec- 
tal enema  of  normal  salt  solution  arranged  for.  The  purpose  of  this 
treatment,  instituted  by  Murphy  with  such  signal  success,  is  to  secure 
a  constant  saline  lavage  of  the  peritoneal  cavity.  In  other  words, 
the  fluid  passes  from  the  bowel  into  the  peritoneal  cavity,  accom- 


FiG.  430. — Diagram  showing  directions  the  pus  may  extend.     A,  Sub-hepatic;  B,  pelvic; 

C,   iliac.      {Veau.) 


plishes  its  healing  mission,  and  drains  out  through  the  abdominal 
wound. 

The  fluid  should  be  maintained  at  a  temperature  of  100°  F.,  and 
should  be  allowed  to  flow  into  the  rectum  at  the  rate  of  i  pint  per 
hour  or  thereabout.  The  patient's  sensation  should  be  consulted. 
If  there  is  a  feeling  of  tightness  and  distress,  the  flow  should  be  les- 
sened.    After    2    or    3    quarts    have    been    introduced,    the  flow 


DRAINAGE 


575 


should  be  shut  off  for  an  hour  or  two.     The  injections  may  be  con- 
tinued one  to  three  days. 

Moynihan  reviews  his  experiences  with  this  treatment  (Lancet, 
Aug.  17,  1907)  and  concludes  that  it  has  exceptional  value.  He 
insists  upon  attention  to  the  details  of  administration  and  describes 
the  methods  found  most  useful.  The  largest  quantity  of  the  solu- 
tion taken  by  any  of  his  patients  was  16  pints  for  the  first 
twenty-four  hours,  and  a  total  of  29  pints    in    three    days.     He 


Fig.  431. — Placing  a  tube  in  the  sub-hepatic  space.     (Veau.) 


emphasizes  the  character  of  improvement  in  the  appearance  of  the 
patient,  in  his  pulse  and  temperature,  and  in  the  action  of  kidneys 
and  skin. 

The  plan  pursued  by  others  aims  to  secure  drainage  by  means  of 
tubes  passed  in  various  directions  into  the  intestinal  mass  and  into 
the  pelvic  cavity.  Under  these  circumstances,  the  enemas  of  nor- 
mal salt  solution  should  be  used  at  intervals  and  the  dressings 
changed  on  the  second  day.  On  the  fifth  day,  the  tubes  should  be 
removed,  cleansed  and  replaced  exactly  as  before.  The  patient 
must  not  strain  while  this  change  is  being  made  and  children  may 
need  to  be  given  a  few  whiffs  of  chloroform.     Cleanse  the  drainage- 


576  APPENDICITIS.      PURULENT   PERITONITIS 

tubes  every  third  day,  gradually  shortening  them  as  granulation 
proceeds. 

If  a  new  focus  of  infection  forms,  if  the  temperature  reaches  beyond 
101°  in  the  evening  for  two  or  three  evenings,  no  matter  what  it  was 
in  the  morning,  one  may  be  sure  of  suppuration  somewhere.  It  will 
be  necessary  to  re-operate  and  re-establish  drainage. 

Septic  peritonitis,  originating  elsewhere  than  the  appendix,  ought 
to  be  similarly  treated,  but  the  results  are  so  discouraging  that  the 
operation  cannot  be  urged  upon  the  general  practitioner,  however 
advisable  it  may  be  in  hospital  practice. 

The  principle  of  treatment  is  the  same.  Make  a  median  incision 
below  the  umbilicus  and  search  for  the  cause.  It  may  originate  from 
a  ruptured  Fallopian  tube,  it  may  follow  perforation  of  the  stomach 
or  duodenum,  and  the  break  must  be  located  and  repaired.  It  may 
follow  the  perforation  of  typhoid  fever  and  for  this  condition,  the 
operation  will  be  done  more  and  more  as  time  goes  by. 

Gerster,  of  New  York,  before  the  1909  Congress  at  Budapest,  sum- 
marizes the  treatment  of  diffuse  free  progessive  peritonitis  thus:  (i) 
Preliminary  lavage  of  the  stomach;  (2)  anesthesia  by  nitrous-oxid 
gas  followed  by  ether;  (3)  rapid  exposure  of  primary  focus  of  infec- 
tion; (4)  stoppage  of  visceral  leak  by  suture  or  tamponade;  (5) 
gentleness  and  rapidity  of  procedure,  avoidance  of  friction  by  wiping, 
etc.;  (6)  no  irrigation;  (7)  soft  rubber-tube  drainage  of  right  iliac 
fossa  and,  if  necessary,  of  Douglas'  pouch;  (8)  closure  of  external 
wound  by  three  layers  of  suture;  (9)  for  paralytic  ileus  repeated 
gastric  lavage,  low  and  high  enemata,  or  systematic  rectal  lavage, 
enterotomy  by  stab  done  in  intractable  cases  only;  (10)  rational 
administration  of  opiates;  (11)  withholding  of  all  ingesta  while  vom- 
iting is  present;  (12)  Murphy's  proctoclysis;  (13)  Fowler's  position; 
(14)  early  incision  and  drainage  of  secondary  abscesses;  (15)  laxa- 
tives, calomel  and  salts,  to  be  given  only  after  cessation  of  vomiting ; 
(16)  tampons  used  for  walling  off  necrosed  areas  not  to  be  disturbed 
without  necessity  till  they  become  detached  of  themselves. 


CHAPTER  IX 
ACUTE  INTESTINAL  OBSTRUCTION 

Acute  occlusion  of  the  intestinal  canal  is  a  condition  always  to  be 
dreaded,  for  it  begins  suddenly  and  unexpectedly  and,  unless  relieved, 
hurries  to  a  fatal  issue,  due  either  to  shock  or  sepsis.  Perhaps,  as 
Bloodgood  says,  the  condition  is  not  a  frequent  one,  yet,  none 
the  less,  it  is  an  emergency  whose  character  must  be  thoroughly 
understood. 

But  for  that  matter  its  character  is  variable,  depending  upon  the 
cause.  To  simplify  the  subject,  the  obstruction  due  to  strangulated 
hernia  is  not  considered  here,  for  in  such  cases  the  cause  of  the  ob- 
struction is  quite  obvious;  nor  need  we  consider  post-operative  ileus, 
for  it  has  a  pathology  of  its  own;  again  the  obstruction  which  may 
accompany  appendicitis  is  in  a  class  by  itself.  The  acute  obstruc- 
tions to  be  studied  include  those  changes  in  the  form  or  direction  of 
the  bowel,  or  those  accumulations  within  its  lumen,  which  completely 
and  suddenly  dam  the  fecal  current.  Whether  it  be  a  kink  or  twist 
in  the  gut;  a  volvulus  or  intussusception;  an  adhesive  or  constricting 
band,  relict  of  a  former  peritonitis  (Fig.  432) ;  an  accumulation  of  gall- 
stones or  a  cancer:  whatever  the  source  of  the  obstruction,  the  danger 
arises,  as  has  been  said,  from  two  sources — shock  and  sepsis.  By  far 
the  lesser  of  these  two  evils  is  shock.  In  many  cases  it  may  be  ab- 
sent, and  even  when  it  is  the  dominant  feature  early  in  the  attack,  it 
may  gradually  subside.  The  sympathetic  plexuses  seem  able  to  re- 
gain their  balance  and  adjust  themselves  to  new  conditions.  For  this 
reason  attacks,  which  begin  with  collapse,  often  seem  to  improve  in  a 
short  time.  But  such  improvement  is  deceptive,  for  sepsis  pursues  its 
insidious  course,  the  bowel  becomes  more  distended,  its  peritoneal 
coat  more  permeable,  and  so  the  intestinal  bacteria  find  their  way 
into  the  peritoneal  cavity  and  their  toxins  into  the  blood.  It  is 
stercoremia,  therefore,  which  is  to  be  dreaded,  for  there  is  no  way  to 
measure  its  progress  with  any  certainty. 
37  577 


578 


ACUTE  INTESTINAL  OBSTRUCTION 


J.  R.  Eastman  reports  a  case  which  illustrates  the  deceptive  char- 
acter of  many  cases  of  obstruction.  The  patient  had  undergone, 
some  years  before,  three  various  abdominal  operations.  The  at- 
tack came  on  suddenly,  and  on  the  third  day  the  vomiting  became 
stercoraceous.  In  preparing  for  the  operation,  high  enemas  were 
given,  followed  by  escape  of  flatus.  The  operation  was  deferred,  as 
the  patient  continued  apparently  to  improve,  the  bowels  moving, 
gas  escaping  freely,  and  the  patient  feeling  quite  comfortable.     Two 


Fig.  432. — Intestinal  obstruction  due  to  band  of  adhesions.     (Reed  and  Carnrick.) 


days  after,  however,  the  fecal  vomiting  re-appeared  and  with  it  all 
the  ominous  signs  of  obstruction.  At  the  operation,  4  inches  of 
small  intestine,  adherent  in  an  inflammatory  mass,  was  found  to  be 
gangrenous.  Resection,  anastomosis,  recovery.  It  is  to  be  noted 
that  the  bowels  had  moved  though  the  gut  was  strangulated  and  gan- 
grenous, the  gas  and  fecal  matter  undoubtedly  passing  the  point  of 
strangulation.  (IndianapoHs  Medical  Journal,  July  15,  1909.) 
The  group  of  symptoms  constitutes  a  very  definite  cHnical  picture: 


DIAGNOSIS    OF    OBSTRUCTION  579 

(a)  pain,  (b)  tympanites,  (c)  vomiting,  (d)  constipation,  and  (e) 
collapse. 

(a)  The  pain  develops  suddenly  and  severely,  often  following 
some  violent  exertion,  and  takes  the  form  of  paroxysmal  colic. 
There  is  localized  tenderness. 

(b)  Tympanites  is  marked,  the  whole  abdomen  being  distended, 
and  often,  on  this  account,  the  respiration  and  circulation  are  im- 
paired. Peristalsis  is  exaggerated,  and  the  violent  movements  of 
the  bowel  may  often  be  noted  through  the  abdominal  wall.  At  the 
site  of  the  greatest  tenderness,  a  tumor  may  be  found. 

(c)  There  is  often  at  first  a  rumbhng  of  the  bowels  and  nausea, 
soon  followed  by  an  incessant  and  distressing  vomiting,  at  first  gas- 
tric and  finally  fecal. 

(d)  Constipation  is  a  constant  feature,  though  at  first  there  may 
be  some  movement  from  the  lower  bowel.  In  intussusception  there 
is  often  all  through  the  attack  some  discharge  of  bloody  mucus  and 
gas.  This  may  be  the  case,  too,  in  strangulation  near  the  pylorus, 
but  in  such  a  case,  the  extreme  distention  of  the  stomach  and  the 
violence  of  its  movements  suggest  the  nature  of  the  difficulty. 

(e)  Collapse  is  imminent  from  the  first,  and  is  indicated  by  the 
weak,  thready  pulse,  the  rapid  breathing,  the  pale,  pinched  features, 
and  the  anxious  expression. 

These  are  the  symptoms,  whatever  the  form  of  the  acute  obstruc- 
tion, whether  it  be  strangulation,  intussusception,  or  volvulus,  and 
very  rarely  can  the  form  of  the  obstruction  be  definitely  determined 
before  the  operation  or  post-mortem. 

Certain  factors  make  one  of  the  conditions  the  most  probable. 
If  it  is  a  child  under  ten  years  of  age,  it  is  almost  certain  to  be  intus- 
susception; if  there  have  been  previous  attacks  of  some  form  of 
peritonitis,  strangulating  bands  of  adhesions  are  Hkely  to  be  present; 
if  the  patient  is  forty  or  fifty  years  of  age,  with  a  history  of  constipa- 
tion, volvulus  suggests  itself. 

In  addition  to  noting  the  symptoms  and  history,  a  careful 
search  must  always  be  made  by  palpation  for  an  abdominal  tumor, 
and  finally  the  investigation  is  terminated  by  rectal  or  vaginal 
examination. 

Treatment. — In  the  few  hours  that  mu^  elapse  before  one  can 


580  ACUTE  INTESTINAL   OBSTRUCTION 

fully  make  up  his  mind  that  it  is  a  case  of  acute  obstruction,  there 
are  certain  things  to  do,  but,  more  especially,  certain  things  not  to 
do.  Do  not  give  purgatives.  This  is  an  axiom  scarcely  necessary 
to  repeat.  They  can  do  no  good  and  will  most  certainly  do  harm. 
Do  not  give  large  and  repeated  doses  of  morphine.  It  will  help  the 
patient  to  die  easy,  but  in  such  a  case,  it  is  '^not  a  remedy  for  the 
patient  but  a  refuge  for  the  doctor."  It  is  doubtful  even  if  it  should 
be  given  at  all.  It  is  possible  that  minute  doses  may  diminish  the 
peristalsis,  quiet  the  vomiting  to  some  extent,  relieve  the  shock  a 
little,  and  ease  the  pain  measurably  without  masking  the  true  con- 
ditions, but  under  the  circumstances,  it  is  an  edged  tool.  Give  no 
nourishment  by  mouth.  The  two  measures  likely  to  be  of  the  great- 
est benefit  are  gastric  lavage  and  rectal  injections. 

The  gastric  lavage  may  in  some  measure  diminish  the  vomiting; 
and,  in  case  an  anesthesia  is  necessary,  it  may  prevent  asphyxia 
from  a  gush  of  vomited  matter. 

Rectal  enemas  are  sometimes  effective  in  relieving  the  obstruction, 
but  if  used,  it  must  be  with  the  strict  proviso  that  the  injection  be 
done  carefully.  If  roughly  given,  if  the  fluid  is  thrown  into  the 
bowel  with  too  much  force,  even  if  there  is  no  danger  of  rupturing 
the  bowel,  it  at  least  irritates  it  and  defeats  its  own  purpose.  It  is 
likely  if  the  condition  has  existed  more  than  twenty-four  hours  the 
enemata  will  be  of  no  avail. 

There  is  a  definite  mode  of  procedure:  put  the  patient  crosswise  in 
bed  in  the  lithotomy  position,  -v^-ith  the  pelvis  turned  slightly  to 
the  right  side.  Anoint  the  anal  region  well  with  vaseline,  and  also 
the  rectal  tube,  which  should  be  of  soft  rubber,  3  or  4  feet  in 
length.  In  the  case  of  an  infant,  a  rubber  catheter  will  serve. 
Guide  the  catheter  with  the  left  index  finger,  and  as  it  enters  the 
rectum  direct  it  backward  at  first  and  then  slightly  to  the  left. 
Keep  hold  of  the  tube  close  up  to  the  rectum,  the  better  to  control 
it.  Push  the  tube  a  little  at  a  time,  and  if  it  meets  with  the  ob- 
struction, withdraw  it  slightly,  and  advance  it  with  a  boring  move- 
ment. Any  force  may  result  in  the  tube  merely  coiling  up  in  the 
rectum,  the  doctor  in  the  meantime  having  the  impression  that  it 
is  ascending  high  in  the  bowel.  Sometimes  it  is  advantageous  to 
let  the  injection  flow  as  soon  as  the  first  part  of  the  tube  is  intro- 


TREATMENT   OF   OBSTRUCTION  581 

duced,  as  by  that  means  the  rectum  is  dilated  and  Houston's  valves 
are  not  so  likely  to  intercept  the  tube.  The  tube  must  be  introduced 
as  high  as  possible  without  using  force.  In  the  great  majority  of 
cases  it  goes  no  higher  than  the  sigmoid. 

Attach  the  fountain  syringe,  holding  it  low  at  first  and  gradually 
raising  it  to  increase  the  pressure.  It  should  not  be  raised  much 
more  than  3  feet  above  the  patient's  level.  The  quantity  of 
fluid,  either  warm  salt  solution  or  oil,  which  may  be  injected,  varies 
with  the  age,  say  1  pint  for  the  infant  and  4  to  6  quarts  for  the 
adult. 

When  the  injection  is  completed,  withdraw  the  tube  rapidly,  and 
lay  the  patient  back  in  bed.  The  enema  will  be  expelled  sooner  or 
later  with  severe  colicky  pains.  If  ineffective,  it  returns  practically 
clear.  If  it  has  done  good,  it  will  be  accompanied  by  flatus,  and, 
at  the  last,  there  will  be  some  hard  lumps.  The  final  evacuation 
may  not  take  place  for  some  time,  but  the  escape  of  gas  is  a  good 
indication  that  the  obstruction  has  been  at  least  temporarily 
relieved. 

If  this  has  not  done  good,  the  enema  should  be  repeated  with  the 
patient  in  the  knee-chest  position. 

Lejars  recommends  the  "electric  bath"  as  efficacious  in  many 
cases,  but  this  treatment  is  scarcely  applicable  in  general  practice. 

On  the  whole,  the  treatment  is  surgical;  and  the  doctor  must  have 
it  on  his  conscience  that  if  the  case  is  acute  obstruction,  delay  is 
dangerous  or  even  fatal.  The  point  is  to  make  the  diagnosis  quickly, 
and  when  that  is  made,  there  is  only  one  thing  to  do,  operate. 

The  practitioner  will  hesitate  between  two  procedures,  median 
laparotomy  and  artificial  anus. 

Median  laparotomy  is  the  ideal  operation.  It,  alone,  is  curative, 
for  the  cause  of  the  obstruction  is  found  and  relieved;  but  it  is  deli- 
cate and  dangerous.  These  are  the  conditions  which  Veau  formu- 
lates, under  which  alone  the  doctor  must  undertake  it: 

(a)  The  operator  must  be  experienced  and  resourceful,  for  it  is 
often  difficult  to  locate  the  cause  and  equally  difficult  to  remove  it, 
and  the  distended  bowel  is  always  a  source  of  embarrassment. 

(b)  The  operation  must  be  conducted  where  there  are  the  surgical 
accessoriesand  capable  assistants. 


582 


ACUTE   INTESTINAL   OBSTRUCTION 


(c)  The  diagnosis  must  have  been  perfected,  so  that  the  operator 
knows  about  what  he  will  have  to  do. 

(d)  The  patient  must  be  vigorous  and  able  to  stand  a  tedious  and 
prolonged  operation. 

These  conditions  are  nearly  always  lacking  when  the  doctor  is 
thrown  absolutely  upon  his  own  resources,  so  it  may  be  laid  down  as 
a  rule  that  the  general  practitioner  must  choose  the  second  pro- 
cedure. 

An  artificial  anus  will  usually  save  the  patient's  life  and  is  within 

the  skill  of  any  doctor  under  almost  any 
circumstances.  After  the  patient  has  later 
regained  his  strength,  the  operation  neces- 
sary to  complete  a  cure  may  be  under- 
taken. It  will  not  be  an  emergency  opera- 
lion,  and  the  time  and  place  maybe  chosen. 
To  make  a  temporary  artificial  anus  will 
be  the  proper  procedure  under  the  circum- 
stances indicated.  There  is  a  single  nota- 
ble exception;  if  the  patient  is  a  child  with 
an  undoubted  attack  of  intussusception, 
and  if  the  enemas  have  failed  to  give  relief,  it  is  imperative  to 
do  a  laparotomy  (Fig.  433). 


Fig.  433. — Inttissusception. 
iWalsham.) 


LAPAROTOMY  FOR  INTUSSUSCEPTION 


Intestinal  invagination  or  intussusception  occurs  only  in  the  first 
years  of  life  for  the  reason  that  the  mesentery  lacks  resistance  at 
that  age.  It  occurs  at  a  point  where  a  mobile  part  of  the  bow^el 
joins  a  part  more  fixed  and  is  most  common  at  the  ileocecal  junction. 

As  a  result  of  colic  or  spasm  the  ileocecal  valve  protrudes  into  the 
cecum  and  is  followed  by  the  ileum  and  its  mesentery  which  alone 
limits  the  extent  to  which  the  large  instestine  may  swallow  the  small 
bowel. 

A  thickened  band  or  collar  marks  the  line  where  the  two  parts 
come  in  contact,  and  this  collar  is  usually  tight;  after  a  little  while 
adhesions  may  here  occur  between  the  invaginating  and  invaginated 
parts. 


INlUSSUSCfcPllUN  S^v^ 

Here  the  strangulation  occurs  and  the  symptoms  are  proportional 
Lo  the  degree  of  strangulation  and  the  rapidity  with  which  it 
occurs. 

A  case  reported  by  Estes  (American  Journal  of  Surgery,  August, 
1906)  illustrates  the  subject  and  emphasizes  the  danger  of  expectant 
treatment. 

A  girl  of  three  years  in  fair  health,  three  days  before  had  been 
seized  with  violent  abdominal  pains  with  straining  and  tenesmus. 
At  first  the  passages  were  fecal  and  then  mucous,  tinged  with  blood. 
She  had  intervals  of  apparent  ease  when  she  would  play  with  her 
toys  and  ask  for  something  to  eat.  After  three  days'  treatment  by 
enemas  and  light  laxatives,  she  developed  signs  of  complete  obstruc- 
tion. The  abdomen  was  distended,  vomiting  frequent  and  at  last 
feculent;  there  was  persistent  pain,  rapid,  weak  pulse,  and  general 
weakness.  At  this  time  Estes  was  called  and  found  a  very  pale, 
emaciated,  weak,  suffering  baby,  with  pulse  130,  and  temperature 
101°.  She  was  vomiting  every  half -hour.  No  distinct  tumor  could 
be  felt,  but  there  was  some  thickening  in  the  right  iliac  region. 
Through  that  night,  while  preparing  for  the  operation  next  morning, 
she  was  given  some  strychnia  and  morphia  and  saline  enemas,  which 
produced  an  improvement. 

Operation — median  incision.  A  hand  passed  into  the  right  iliac 
fossae  located  the  sausage-shaped  tumor  of  an  ileo-cecal  intussuscep- 
tion. Turning  the  child  to  get  the  intestines  out  of  the  way,  gentle 
milking  motions  were  made  and  almost  immediately  the  intussuscep- 
tion was  reduced.  Inspection  showed  a  very  much  thickened  and 
inflamed  section  of  the  ileum  about  6  inches  long.  It  was  decided 
not  to  exsect  the  injured  gut.  The  torn  border  of  the  mesentery 
was  sutured,  the  peritoneal  coat  bathed  with  hot  saline  solution, 
dried,  sprinkled  with  aristol  and  replaced,  and  the  abdomen  rapidly 
closed.  The  child  made  a  rapid  and  uninterrupted  recovery  and 
has  been  quite  well  ever  since. 

The  principal  steps  in  the  operation  are  as  follows : 
(i)  Median  laparotomy.     Be  careful  in  opening  the  peritoneum 
not  to  wound  the  distended  bowel.     Expect  to  find  trouble  in  the 
management  of  the  bowel.     A  skillful  assistant  is  a  great  comfort  in 
this  matter. 


584 


ACUTE   INTESTINAL   OBSTRUCTION 


(2)  Search  for  the  obstruction.  The  obstruction  is  usually  easily 
found  in  intussusception.  After  the  abdomen  is  opened,  proceed 
directly  to  the  right  iliac  fossa,  having  no  fear  to  introduce  the  whole 
hand,  if  gently  done.  In  any  case  the  cecum  is  first  to  be  examined, 
for  by  its  condition  one  can  determine  whether  the  obstruction  is  in 
the  large  or  small  intestine. 

The  sausage-shaped  tumor  (in  the  case  of  intussusception)  is 
pulled  up  into  the  wound  and  its  topography  carefully  noted  and 
the  intesritv  of  the  srut  determined.     If  there  are  no  adhesions,  if 


Fig.  434. — Senn's  method  of  performing  taxis  in  reducing  an  invagination. 


there  are  no  appearances  of  gangrene;  in  other  words,  if  the  accident 
is  recent,  try  to  reduce  the  bowel. 

(3)  Disinvaginate,  follo\^ing  the  procedure  of  Senn,  which  has 
for  its  aim  first  to  reduce  the  edema.  This  is  to  be  accompHshed  by 
steady  and  uninterrupted  manual  compression  of  the  tumor. 

As  soon  as  the  swelling  is  reduced,  grasp  the  bowel  below  the  tumor 
and  press  gently  but  firmly  against  the  apex  of  the  intussusceptum, 
at  the  same  time  making  easy  traction  at  the  other  end  (Fig.  434). 
Remember  it  is  easy  to  tear  the  bowel  or  mesentery. 


INTUSSUSCEPTION 


585 


When  the  bowel  is  reduced,  examine  again  for  gangrene.  If 
there  are  points  of  disintegration,  cover  them  in  by  Lembert  sutures. 
If  the  whole  segment  of  the  bowel  is  gangrenous,  it  must  be  resected; 
or  if  doubtful,  retained  in  the  wound  for  further  inspection.  If  the 
bowel  is  not  impaired,  wash  and  return;  and  the  operation  is  com- 
pleted by  the  repair  of  the  abdominal  wall. 

If,  as  Senn  says,  repeated  attempts  at  reduction  fail,  one  of  two 
courses  must  be  pursued:  the  establishment  of  an  intestinal  anasto- 
mosis or  resection  of  the  invaginated  portion;  but  the  latter,  on  ac- 


FiG.  435. — Intussusceptum       exposed. 
(Guibe.) 


Fig.  436. — Intussusceptum   resected. 
(jGuibe.) 


count  of  the  time  required,  must  not  be  undertaken  unless  the 
invaginated  parts  are  gangrenous. 

The  anastomosis  between  the  parts  of  the  bowel  above  and  below 
the  invagination  may  be  accomplished  by  suture  or  the  Murphy 
button.  The  technic  of  resection  of  the  invaginated  portion  is 
represented  in  Figs.  435,  436,  437,  and  438. 

The  predisposing  cause  of  these  attacks  of  intussusception  is  often 
acute  indigestion. 

The  pain,  which  is  the  first  symptom,  is  often  merely  colicky  at 
first,  but  later  may  be  persistent.     Vomiting  is  common  but  not 


S86 


ACUTE   INTESTINAL   OBSTRUCTION 


nearly  so  severe  as  in  other  forms  of  obstruction,  nor  does  it  appear 
so  early.  The  temporary  relief  following  the  vomiting  is  character- 
istic of  intussusception.  The  nearer  the  duodenum  the  invagination 
is  situated,  the  more  severe  the  vomitus.  Rigidity  is  not  an  early 
symptom.  Distention  is  absent  until  late.  Tenderness  is  also  a 
late  symptom;  indeed,  in  the  early  stages,  pressure  may  give  relief. 
The  presence  of  a  tumor  is  of  great  diagnostic  value;  it  is  usually 
movable,  hard,  and  resistant.     Its  size  gives  no  idea  of  the  amount  of 


Fig.  437. — Anastomosis  after  resection. 
{Guihe.) 


Fig.  438. — Repair  of  the  bowel  and  appli- 
cation of  Lembert  sutures  over  the  site 
of  anastomosis.     (jGuibe.) 


bowel  involved.  Tenderness  is  a  severe  and  early  symptom;  thirst 
not  marked.  Early  diagnosis  and  early  operation  are  the  Ufe-saving 
factors  in  these  cases. 


POST-OPERATIVE  ILEUS 

The  acute  obstruction  of  the  bowel  which  may — which  too  often 
does — follow  laparotomy  is  one  of  the  tragic  accidents  of  surgery. 
An  operation  of  comparative  simplicity  may  terminate  uneventfully; 
the  patient  rallies  from  the  anesthetic,  seems  to  feel  well,  and  with 


POST-OPERATIVE   ILEUS  587 

the  family  is  happy  at  the  thouj^ht  of  danger  passed.  Twenty-four 
hours  pass  and  it  is  noticed  that  the  temperature  falls  to  subnormal 
perhaps,  and  then  begins  slowly  to  rise.  The  pulse,  at  first  90  to 
100  and  of  fair  volume,  slowly  increases  in  rate  while  decreasing  in 
force.  The  patient's  mind,  perfectly  clear  in  the  first  instance, 
begins  in  a  little  while  to  be  disturbed,  and  he  grows  anxious  as  to 
the  outcome  or  perhaps  calmly  forecasts  the  end. 

In  the  meantime  the  tympanites  has  become  marked,  but  no  gas 
passes  per  rectum;  and  there  is  no  sign  of  movement  or  peristalsis, 
in  the  distended  gut.  The  pain  is  not  severe,  the  chief  distress  is 
want  of  air;  the  patient  complains  that  he  cannot  get  a  good  breath; 
nausea  develops,  and  finally  continuous  vomiting.  If,  now,  the 
ordinary  means  of  relief  of  gaseous  distention  fail  and  the  symptoms 
do  not  in  any  respect  improve,  one  may  conclude  that  he  has  to  deal 
with  an  intestinal  paralysis.  In  simple  tympanites  the  pain  is 
colicky  in  its  nature,  there  is  little  disturbance  in  pulse  and  tempera- 
ture, the  vomitus  is  more  nearly  normal  in  character.  But  in  spite 
of  these  distinguishing  features,  it  may  be  impossible  to  say,  during 
the  first  few  hours,  whether  the  obstruction  is  serious  or  not.  In 
any  event,  certain  measures  should  be  employed:  If  there  is  much 
nausea  or  any  evidence  of  gastric  dilatation  the  stomach  should  be 
washed  out  and  J/^o  grain  calomel  given  every  half-hour  for  at  least 
ten  doses.  At  the  other  end  of  the  alimentary  tube,  the  attempt  at 
relief  is  begun  w^ith  an  ordinary  soapsuds  enema.  If  no  flatus  passes, 
a  Watkin's  enema  is  next  to  be  tried,  or  one  which  consists  of 

ISIagnesia  sulphate,   • 
Glycerin;  aa     5  ij 

Turpentine,  5j 

A  large  tube  should  be  employed,  but  no  eftort  made  to  introduce 
it  high.  Elevate  the  hips  and  inject  the  fluid  slowly,  and  thus  let  it 
find  its  ow^n  way  up  the  bowel.  If  gastric  lavage  and  the  persistent 
use  of  enemas  fail  to  give  any  relief,  if  the  judicious  use  of  hypodermic 
injections  of  morphin  and  atropia,  eserine,  and  pituitrin  are  with- 
out effect  to  awaken  the  intestine  or  to  sustain  the  patient's  vitality, 
the  only  thing  left  which  offers  any  hope  is  an  enterostomy.  This 
may  be  done  under  local  anesthesia.     The  bowel  through  this  open- 


588  ACUTE    INTESTINAL    OBSTRUCTION 

ing  is  to  be  kept  washed  out  ^sdth  normal  salt  solution.  By  this 
means  the  toxemia  may  be  kept  under  control  until  the  patient's 
forces  rally. 

But,  after  all,  the  chief  treatment  of  post-operative  intestinal  paral- 
ysis is  prophylactic  and  preventive.  By  washing  out  the  stomach, 
by  having  the  bowel  well  emptied  with  castor  oil,  by  treating  the 
exposed  gut  with  scrupulous  care,  one  may  hope  to  reduce  these 
accidents  to  the  minimum.  Slight  traumatisms  of  the  mesentery 
in  the  course  of  the  operation,  slight  infections  introduced  in  the 
clean  cases  are  at  the  bottom  of  these  surgical  disasters.  If  they 
result  from  infections  already  fixed  upon  the  peritoneum  before 
operation,  the  surgeon  may  have  a  balm  for  his  conscience  but  no 
excuse  to  relax  his  precautions. 

In  all  operations  in  which  there  is  a  diffused  peritonitis  in  order  to, 
prevent  post-operative  ileus,  Heile  injects  50  to  100  c.c.  castor  oil  in  a 
loop  of  the  small  intestine.  The  puncture  of  the  gut  is  closed  by  a 
small  silk  suture.  He  claims  excellent  results.  (Zeitblatt  f .  Chirurg. 
Leipsic,  July  31,  1909.J 


CHAPTER  X 
ARTIFICIAL  ANUS:  TEMPORARY;  PERMANENT 

TEMPORARY  ARTIFICIAL  ANUS— ENTEROSTOMY 

An  acute  obstruction  of  the  bowel  may  necessitate  a -temporary 
drainage  through  the  abdominal  wall.  This  will  be  the  case  when 
circumstances  such  as  environment,  lack  of  experience,  assistance,  or 
equipment  preclude  a  laparotomy;  or  even  when  a  laparotomy  is 
done  and  it  is  found  impossible  at  the  time  to  remove  the  cause. 

Enterostomy  is  therefore  a  life-saving  operation  which  every 
practitioner  must  know  how  to  perform. 

The  operation  proposes  opening  the  abdomen,  anchoring  a  loop  of 
intestine  in  the  abdominal  wound  and  opening  this  loop  to  secure 
drainage.  The  incision  will  be  made  ordinarily  in  the  right  iliac 
fossa  and  the  opening  in  the  bowel  made  above  the  obstruction. 
For  that  matter,  one  need  scarcely  fear  that  he  will  open  into  the 
bowel  below  the  constriction,  for  it  is  only  the  distended  portion  that 
will  present.  It  is  preferable  to  open  the  cecum,  but  if  it  is  not  avail- 
able, whatever  loop  presents  will  do. 

No  special  instruments  are  required.  It  is  a  good  idea  to  have 
several  needles  already  threaded  with  silk  No.  o  or  No.  i.  Local 
anesthesia  may  suffice. 

Incision. — Begin  by  dividing  the  skin  and  fat  along  a  line  two 
fingers'  breadth  from  the  anterior  superior  iliac  spine,  parallel  with 
the  fibers  of  the  external  oblique — an  incision  about  3  inches  long, 
whose  central  point  corresponds  to  the  anterior  superior  iliac  spine 
(Fig.  439).     Catch  up  the  two  or  three  bleeding  points. 

This  first  incision  exposes  the  external  oblique  (Fig.  426)  and  the 
second  divides  that  muscle  in  the  same  Hne.  Catch  up  the  edges  of 
the  divided  muscle.  In  the  same  manner,  the  third  incision  divides 
the  internal  oblique  and  transversalis,  and  finally  exposes  a  fibrous 
layer,  the  transversalis  fascia,  which  is  carefully  divided  in  order  to 

589 


590 


ARTIFICIAL    anus:    TEMPORARY;    PERMANENT 


reach  the  peritoneum  (Fig.  428).  Pick  up  a  fold  of  that  membrane 
with  the  dissecting  forceps  and  incise  it  at  its  base,  remembering 
that  the  distended  bowel  is  in  close  contact  (Fig.  422). 

A  reddish  fluid  escapes  as  soon  as  the  peritoneum  is  opened;  seize 
each  lip  with  forceps  and  enlarge  the  opening,  but  not  to  the  full  ex- 
tent of  the  skin  wound.  Restrain  the  bulging  gut  with  compresses. 
Introduce  the  index  finger  and  examine  in  various  directions  for  a 
source  of  obstruction.     Happily  it  may  be  found  and  relieved  with- 


FiG.  439. — Trace  of  incisions  for  artificial        Fig.  440. — ^Locating  the  cecum.     (Veau.) 
anus:  on  the  right,  temporary;  on  the  left, 
permanent.     {Veau.) 


out  loss  of  time.  Usually,  however,  it  will  not  be  and  one  must  not 
persist  in  his  search  or  effort  at  relief.  Attempt  next  to  locate  the 
cecum,  passing  the  index  finger  down  into  the  iliac  fossa,  following 
the  external  wall  (Fig.  440). 

If  successful  in  locating  it,  pull  it  up  into  the  wound  mth  index 
finger  and  thumb  and  hold  it  with  two  artery  forceps.  It  is  easily 
identified  by  the  appendices  epiploicae  and  by  its  bands.  If  the 
cecum  cannot  be  reached,  employ  any  loop  which  presents. 

Anchor  the  bowel.  The  bowel  is  sutured  to  the  abdominal  wall 
in  this  manner:     Commence  at  one  angle,  passing  the  needle  through 


TEMPORARY   ARTIFICIAL   ANUS 


501 


the  parietal  peritoneum  of  one  side,  through  the  serous  and  muscular 
coats  of  the  bowel,  and  through  the  peritoneum  of  the  opposite  side. 


Fig.  441. — Attaching  the  bowel  in  the  angle     Fig.  442. — Attaching  the  bowel  laterally. 
of  the  wound.     (Veau.)  (Veau.) 


Fig.  443. — Diagram   showing   disposition   of     Fig.  444. — Opening    of    the     bowel     with 
sutures.     (Veau.)  thermocautery.     {Veau.) 

Tie,  but  do  not  cut  the  threads  (Fig.  440).  Now  make  on  each  side 
three  or  four  "U"  sutures  H  ii^ch  apart  in  this  manner:  the 
needle  passes  through  the  parietal  peritoneum,  the  mucous  and 


592 


ARTIFICIAL   anus:    TEMPORARY;   PERMANENT 


muscular  coats  of  the  bowel,  and  out  through  the  parietal  peritoneum 
of  the  same  side.  Do  the  same  on  the  opposite  side  (Fig.  442). 
Collect  the  loose  ends  of  the  sutures  of  the  same  kind  in  one  forceps. 
In  placing  the  sutures,  do  not  let  the  protruding  segment  of  bowel 
get  folded  or  wrinkled. 

Suture  the  remaining  angle  in  the  same  manner  as  the  first  and 
complete  the  repair  of  the  peritoneal  wound.  The  loop  of  bowel 
may  not  occupy  all  of  it  and  these  peritoneal  sutures  are  cut  short  at 
once.     (The  relative  position  of  the  sutures  is  represented  in  Fig.  443.) 

Now  repair  the  superficial  wound  by  interrupted  sutures  in  two 


Fig.   445. — Temporary    artificial    anus. 
(Veau.) 


Fig.  446. — Incisions     for    temporary    and 
permanent  artificial  anus.      {Veau.) 


layers,  one  reuniting  the  muscles  and  fascia;  the  other,  the  skin. 
The  opening  left  immediately  over  the  anchored  gut  is  about  an 
inch  in  length.     Cut  the  threads  short. 

Open  the  bowel.  This  is  reserved  for  the  last,  and  here  the  long 
threads  of  the  lateral  bowel  suture,  left  until  this  time,  are  used  to 
pull  the  bowel  well  into  view  (Fig.  444).  Incise  it  with  the  bistoury 
for  about  an  inch,  and  there  is  an  immediate  escape  of  gas. 

Cut  short  all  the  sutures.  The  bowel  will  not  immediately  empty 
itself.  It  wdll  require  possibly  twenty-four  hours,  during  which  time 
the  dressing  should  be  changed  every  half-hour,  afterward  twice 
daily  is  sufficient. 


PERMANENT   ARTIFICIAL   ANUS 


593 


Remove  the  cutaneous  sutures  on  the  sixth  day,  else  later  they  will 
become  septic.     Apply  ointments  to  the  inflamed  skin. 

When  the  bowel  is  once  emptied,  which  may  require  as  long  as 
twenty-four  hours,  seek  to  locate  the  site  of  the  obstruction  and  to  de- 
termine its  nature.  See  if  an  enema  will  find  exit  at  the  wound  or  if 
an  injection  at  the  wound  will  discharge  per  anum  (Fig.  445).     A 


Fig.  447. — Opening  the  peritoneum,     (ptiibe.) 

month  later  when  the  patient  has  regained  his  strength,  if  the  bowel 
has  not  become  normal,  send  him  to  a  specialist. 


PERMANENT  ARTIFICL\L  ANUS 

This  operation,  palliative  in  the  treatment  of  cancer  of  the  rectum, 
comes  within  the  scope  of  every  doctor.  It  may  even  be  regarded  as 
an  emergency.  There  may  come  a  time  in  the  history  of  the  case 
when  the  content  of  the  bowel  can  no  longer  pass  and  the  pain  is  un- 
bearable. Then  the  operation  will  give  great  relief.  The  patient 
suffers  little  pain  after  the  operation,  gains  in  weight,  believes  that  he 
is  going  to  get  well,  and  so  dies  happy. 

In  this  case,  the  opening  is  to  be  in  the  sigmoid;  it  may  need  to  be 
38 


594 


ARTIFICIAL   anus:   TEMPORARY;   PERMANENT 


large.     The  bowel  is  completely  divided  transversely  and  the  two 
ends  anchored  separately  in  the  ivound. 


Fig.  448. — The  sigmoid  flexure  drawn  out  through  the  incision.     Note  the  appendices 

epiploicae.     (Veau.) 


Fig.  448. — A  forceps  used  to  make  an  opening  in  the  mesentery.     (Veau.) 

The  operation  is  best  done  in  two  stages.  In  the  first,  the  sigmoid 
is  drawn  out  and  permitted  to  acquire  adhesions.  Subsequently  the 
loop  is  resected. 


I'LIKMANKNT    ARTIFICIAL    ANUS 


505 


First  Stage. — An  inciswn  2  inches  in  length  is  made  obHquely 
over  the  left  iliac  fossa,  a  couple  of  fingers'  breadth  within  the  an- 
terior superior  spine.  The  lower  end  of  the  incision  reaches  to  just 
above  the  level  of  the  spine  (Fig.  446).  Dividing  the  skin  and  cellu- 
lar tissue,  there  will  be  some  small  vessels  to  ligate.     The  fibers  of  the 


Fig.  450. — Bowel  retained  by  strip  of  iodoform  gauze.     {Veau.) 


external  oblique  appear,  running  parallel  with  the  incision.  Separa- 
rate  them  in  the  line  and  length  of  the  skin  incision  by  blunt  dissec- 
tion. Widely  separate  the  two  portions  of  the  muscle  with  retractors. 
In  the  bottom  of  the  wound  are  seen  the  fibers  of  the  internal 
oblique  and  transversalis  which  lie  at  right  angles  to  the  external 
oblique.  Open  through  them  by  blunt  dissection  in  the  direction  of 
their  fibers  and  retract  (Fig.  447). 


Fig.  451. — Dividing  the  loop  with  the  thermocautery.     (Veau.) 

Divide  the  transversalis  fascia  and  expose  the  peritoneum.  This 
is  opened  and  its  lips  seized  with  the  forceps.     Remove  the  retractors 

Search  for  the  sigmoid.  Introduce  the  index  finger  into  the  iliac 
fossa,  following  the  posterior  wall  until  arrested  by  the  meso-sigmoid. 
In  this  manner  locate  the  sigmoid  flexure,  and  with  finger  and  thumb. 


596 


ARTIFICIAL   anus:    TEMPORARY;    PERMANENT 


draw  it  to  the  surface  by  gentle  but  persistent  traction.  It  can  be 
felt  to  yield.  Once  the  loop  is  exposed,  the  only  difficulty  is  over- 
come. The  sigmoid  is  identified  by  the  appendices  epiploicae 
(Fig.  448). 

Spread  out  the  gut  and  find  the  least  vascular  part  of  the  exposed 
mesentery  and  this  part  transfix  (Fig.  449)  with  a  closed  forceps. 
Opening  the  forceps,  let  it  seize  a  roll  of  iodoform  gauze  of  the  caliber 
of  the  index  finger  and  draw  it  into  place.  It  will  hold  the  bowel  in 
position  (Fig.  450). 


Fig.  452. — Upper  orifice  com- 
municates with  bowel;  lower  with 
rectum.      (I'eau.) 


Fig.  453. — Permanent  artificial  anus. 
External  opening  of  bowel  with  spur 
leading  to  rectum.      {Veau.) 


If  the  cutaneous  wound  is  too  large  and  does  not  fit  closely  to  the 
projecting  loop,  it  may  be  diminished  by  a  suture  or  two. 

Dress  with  sterile  gauze  and  do  not  change  until  ready  to  resect, 
unless  the  dressing  becomes  loosened  or  soiled.  Keep  the  patient 
on  a  light  diet,  chiefly  milk. 

Second  Stage. — Resect  the  bowel.  On  the  second  or  third  day,  when 
the  bowel  has  acquired  adhesions,  return  with  a  thermo-cautery  and 
artery  forceps;  there  might  be  an  arteriole  to  ligate.  No  anesthesia 
is  necessary,  for  the  gut  is  quite  insensitive. 

The  thermo-cautery  is  heated  to  a  dark  red  (if  at  a  white  heat, 
there  may  be  a  little  bleeding),  and  with  it  the  bowel  is  completely 


PERMANENT   ARTIFICIAL   ANUS  597 

divided.  Do  not  stop  until  the  roll  of  iodoform  gauze  is  completely 
exposed.  The  few  minutes  required  will  necessarily  seem  a  long 
time,  but  do  not  get  disturbed  (Fig.  451).  When  the  section  is 
complete,  the  gauze  may  be  readily  removed  (Veau) . 

Apply  a  dry  dressing.  On  the  second  day  give  a  laxative.  After 
a  while  the  patient  will  be  able  to  regulate  his  passages  to  a  degree. 

Through  the  lower  orifice  the  cancer  may  be  douched  and  the 
fluids  will  find  their  way  out  per  anum  (Figs.  452,  453). 

Do  not  neglect  to  warn  the  family  that  the  end  must  come  within 
from  eight  to  fifteen  months.  As  for  the  patient,  it  were  better  to 
ease  his  mind  by  vague  references  to  the  future  closure  of  the  wound 
so  repulsive  to  him. 


CHAPTER  XI 
STRANGULATED  HERNIA 

What  doctor  in  general  practice  has  not  had  his  experiences  with 
strangulated  hernia?  And  how  many  have  escaped  the  conviction 
that  it  is  an  emergency  deserving  its  e\'il  fame? 

But,  after  all,  its  sinister  reputation  our  predecessors  have  be- 
queathed us  and,  along  with  it,  interminable  discussions  touching  the 
agent  of  constriction  and  the  indications  for  taxis. 

To-day  we  reverently  lay  aside  those  old  notions,  for  we  know  that 
no  other  equally  dangerous  condition  yields  better  results  to  appro- 
priate treatment.  By ''  appropriate  treatment "  is  meant  early  opera- 
tion. The  indications  for  operation  there  is  no  need  to  discuss,  for 
operation  is  always  indicated. 

Taxis  is  an  exceptional  procedure,  permissible  only  as  a  tentative 
measure  under  certain  well-defined  restrictions;  and  even  then  to  be 
used  \\\ih  fear,  for  who  can  certainly  tell  that  he  has  not  reduced  a 
gangrenous  and  perforated  gut;  and  who  but  the  most  experienced 
may  not  be  misled  by  certain  forms  of  incomplete  reduction? 

The  danger  from  strangulated  hernia  was  formerly  supposed  to 
arise  solely  from  interference  with  the  circulation  and  the  consequent 
gangrene  of  the  incarcerated  loop,  and  the  attention  was  centered 
chiefly  upon  the  mechanical  element.  It  was  perhaps  legitimate 
upon  that  hypothesis  to  treat  expectantly  or  by  repeated  efforts  at 
taxis  an  incompletely  strangulated  hernia. 

But  now  it  is  definitely  determined  that  the  chief  source  of  danger 
is  septic  absorption,  and  in  a  given  case  long  before  the  incarcerated 
bowel  has  ceased  to  be  viable,  the  patient  may  be  overwhelmed  by 
toxins  of  a  virulent  type.  It  is  this  systemic  poisoning  that  makes 
strangulated  hernia  dangerous,  and  which  especially  makes  the 
operation  dangerous.     It  is  for  that  reason  that  procrastination  is 

598 


DIAGNOSIS    OF   STRANGULATION 


599 


so  ofleii  fatal.  So  frequently  it  happens  with  these  attacks  that  after 
hours  of  waiting,  or  after  repeated  efforts  at  reduction,  the  patient  is 
finally  turned  over  to  the  operator;  and  though  the  operation  be  of 
short  duration  and  simple,  yet  the  patient  dies,  for  the  reason  that 
his  powers  of  resistance  were  paralyzed  by  sepsis  unsuspected.  He 
was  a  veritable  victim  of  delay. 

The  thought  to  be  kept  uppermost,  then,  in  treating  strangulated 
hernia  is  not  so  much  that  the  bowel  is  becoming  gangrenous  as  that 
sepsis  is  imminent. 

Th£  diagnosis  is  not  difficult,  as  a  rule.  Usually  the  patient  is 
known  to  have  a  hernia;  suddenly  it  becomes  painful  and  irreducible; 
the  bowels  refuse  to  move  and  become  tympanitic;  nausea  and  vom- 
iting ensue;  and  there  are  signs  of  circulatory  depression.  The  gen- 
eral symptoms  are,  in  fact,  those  of  intestinal  obstruction.  The  face  is 
drawn  and  pinched,  the  lips  white  and  the  eyes  sunken.  There  is  a 
clammy  sweat.  The  symptoms  may  all  be  mild  at  first,  especially 
when  the  obstruction  is  not  complete,  or  in  the  aged  or  debilitated, 
or  if  the  bowel  is  surrounded  by  omentum  which  at  first  bears  the 
brunt  of  the  compression.  It  must  be  kept  in  mind  that  this  mild 
onset  may  be  wholly  deceptive. 

It  may  be  necessary  to  distinguish  between  an  inflamed  and  ob- 
structed irreducible  hernia  on  the  one  hand  and  strangulated  hernia 
upon  the  other;  in  the  first,  pain  and  vomiting  are  not  so  severe, 
there  is  no  collapse,  and  an  impulse  in  coughing  can  always  be 
detected.  If  a  hernia  was  not  before  suspected,  a  careful  examina- 
tion for  one  must  be  made  in  cases  of  intestinal  obstruction.  Small 
sciatic  or  obturator  herniae  are  easily  overlooked.  This  is  likewise 
true  of  small  femoral  hernia  in  fat  subjects. 

Torsion  of  the  spermatic  cord  or  strangulation  of  an  undescended 
testicle  may  simulate  strangulated  hernia,  but  the  indurated  and  very 
painful  inguinal  tumor,  together  with  the  'cryptorchism,  should 
suggest  the  nature  of  the  attack. 

As  Senn  says,  the  differential  diagnosis  between  a  suppurative 
lymphadenitis  in  the  groin  and  a  strangulated  inguinal  hernia  may  be 
very  difficult.  He  points  out  the  necessity  for  caution  in  using  the 
knife  if  the  inflammatory  swelling  is  single  and  occupies  the  site  of 
a  femoral  hernia.     In  such  a  case  the  supposed  gland  should  be 


6oo  STRANGULATED  HERNIA 

approached  by  a  careful  dissection.  If  it  proves  to  be  a  hernia  no 
harm  is  done. 

An  accumulation  of  peritoneal  fluid  in  the  imperfectly  closed  proc- 
essus vaginalis  in  the  very  young  may  give  rise  to  symptoms  of 
strangulation,  but  strangulated  hernia  is  rare  in  infants.  In  such  a 
case,  inversion  of  the  patient  for  a  few  minutes  will  often  empty  the 
sac  and  clear  up  the  diagnosis. 

As  has  been  said  the  indication  for  treatment  is  operation  as  soon  as 
the  diagnosis  is  made.  There  are,  however,  exceptional  instances  in 
which  judicious  efforts  at  taxis  may  be  applied  without  greatly 
prejudicing  the  prognosis.  But  it  is  recommended  without  enthu- 
siasm and  only  out  of  due  respect  to  those  circumstances  of  time  and 
place  which  seem  to  preclude  immediate  herniotomy. 

Taxis  and  operation,  then,  represent  the  sole  measures  of  relief. 
Certainly  no  doctor  at  the  present  time  would  expect  anything  but 
harm  from  the  use  of  drugs. 

As  Senn  says  (Practical  Surgery),  no  modern  physician  would  for 
a  moment  consider  seriously  the  therapeutic  value  of  nauseating 
enemata,  or  the  internal  use  of  relaxing  antispasmodic  remedies,  so 
much  relied  upon  in  facilitating  taxis  before  herniotomy  was  shorn  of 
its  great  mortality  by  the  introduction  of  antiseptic  surgery. 

Taxis. — Taxis,  or  the  reduction  of  a  hernia  by  methodical  manipu- 
lation without  instruments,  is  permissible  only  under  these  circum- 
stances: (a)  The  case  is  seen  soon  after  the  strangulation  began; 
the  hernia  is  of  moderate  size;  the  abdominal  symptoms  are  not 
severe. 

(b)  The  patient  is  an  old  man  debilitated,  manifestly  a  poor  sub- 
ject for  an  operation;  he  has  had  trouble  before;  it  is  only  a  few 
hours  since  his  hernia  became  irreducible. 

Under  these  circumstances  use  taxis,  and  it  will  not  be  dangerous 
if  properly  applied  and  not  repeated.  The  further  proviso  must  be 
made  that  if  it  fails  an  immediate  operation  must  be  done.  In  the 
milder  cases  Senn  advises  that  taxis  may  sometimes  be  facilitated  by 
administering  a  dose  of  opium  and  giving  a  high  enema.  A  full  hot 
bath  in  many  instances  has  an  excellent  effect. 

In  the  severer  cases  a  general  anesthesia  is  always  required .  B  ef  ore 
beginning  the  anesthesia  prepa,rc  the  patient  for  operation  so  that 


REDUCTION  BY   TAXIS  6oi 

if  taxis  fails  no  time  need  be  lost  and  a  single  anesthesia  will  serve 
both  for  the  taxis  and  the  operation.  Chloroform  is  usually  prefer- 
able to  ether  if  it  is  expected  that  taxis  will  succeed.  It  permits 
a  greater  relaxation. 

Technic  of  Taxis:  Inguinal  Hernia.— Elevate  the  hips,  flex  and 
separate  the  thighs  in  order  to  relax  the  external  ring.  Grasp  the 
tumor  with  the  right  hand  (hernia  on  right  side)  so  as  to  compress 
it  uniformly  with  the  tips  of  the  fingers  and  thumb.  Seize  the 
neck  at  the  external  ring  between  the  thumb  and  forefinger  of  the 
left  hand.  While  the  right  gently  compresses  the  tumor,  the  left 
empties  the  gut  by  stripping  in  the  direction  of  the  external  ring  at 
first,  and  later  along  the  inguinal  canal.  The  sole  aim  of  this  first 
maneuver  is  to  empty  the  gut.  The  manipulations  must  be 
made  methodically,  without  interruption  and  without  force.  If 
compression  reveals  the  presence  of  a  doughy  mass,  it  is  omentum, 
and  as  it  probably  occupies  the  lower  part  of  the  sac  it  will  be  better 
to  compress  nearer  the  neck  in  order  to  deal  more  directly  with  the 
intestine.  Sometimes,  to  make  traction  on  the  tumor  while  the 
fingers  at  the  neck  continue  the  kneading  will  start  the  bowel  con- 
tents toward  the  abdominal  cavity.  If  the  tumor  under  these  manipu- 
lations grows  smaller  and  softer,  it  is  some  guarantee  of  success. 
When  the  bowel  is  sufficiently  emptied,  it  then  becomes  reducible 
and  its  return  to  the  abdominal  cavity  is  announced  by  a  gurgling 
or  a  marked  sense  of  yielding. 

When  the  bowel  is  reduced,  the  omentum,  if  present,  should  be 
returned  in  the  same  manner.  One  should  not  persist  if  the  mass 
is  thick  and  adherent  for  there  is  risk  of  rupture  of  an  omental  vessel, 
which  may  be  followed  by  hemorrhage,  all  the  more  grave  because 
unperceived. 

After  the  hernia  is  reduced  the  patient  must  be  put  to  bed  and  no 
food  by  mouth  permitted  for  at  least  twenty-four  hours.  Before 
getting  about,  a  truss  must  be  fitted. 

If  after  ten  or  fifteen  minutes  of  gentle  effort  the  hernial  tumor 
remains  unchanged  in  size  and  hardness,  it  is  a  waste  of  time  to 
prolong  the  procedure.  It  cannot  be  said  too  often  that  repeated  at- 
tempts are  injurious,  becoming  with  each  repetition  more  and  more 
harmful  and  illusory. 


6o2 


STRANGULATED   HERNIA 


It  may  happen  that  after  the  hernia  has  been  apparently  reduced 
the  symptoms  of  obstruction  still  persist,  or  even  if  at  first  relieved, 
appear  again.  The  tympanites  augments,  the  nausea  and  vomiting 
continue,  and  the  signs  of  sepsis  progress.  It  is  evident  that  some- 
thing is  amiss.  One  of  several  things  may  have  happened,  but  no 
time  is  to  be  wasted  in  conjecture,  for  only  the  operation  which  must 
follow  will  definitely  clear  up  the  doubt. 

It  may  be  that  the  hernial  tumor  has  been  reduced  en  masse. 
The  hernial  sac  and  its  contents  have  been  carried  through  the  ex- 
ternal ring  without  having  changed  their  relations  and  the  constric- 


FiG.  454. — Strangulated    hernia    reduced 
en  masse"  iMoullin.) 


Fig.  455. — Incomplete  reduc- 
tion of  strangulated  loop.  Hernia 
in  a  diverticulum.     (Moullin.) 


tion  persists  (Fig.  454).  This  can  occur  in  recent  hernia  in  which 
the  sac  is  not  adherent  and  is  most  common  in  the  direct  form  of 
inguinal  hernia. 

It  may  be  that  instead  of  entering  the  peritoneal  cavity  the  herni- 
ated loop  has  entered  a  diverticulum  of  the  sac  near  the  neck  and 
there  becomes  once  more  strangulated  (Fig.  455). 

It  may  be  that  the  neck  of  the  sac  has  torn  loose  from  the  rest  of 
the  sac  and  has  been  reduced  with  the  gut,  the  strangulation  still 
being  maintained  (Fig.  456). 

Again,  a  rent  may  be  torn  in  the  sac  and  the  gut  escaping  there- 


HERNIOTOMY 


603 


A 


-    B 


C 


from  pushes  up  between  the  peritoneum  and  the  abdominal  wall 

(Fig.  457)- 

Finally  the  reduction  may  have  been  complete,  but  the  gut  was 
gangrenous  or  ruptured  and  a  general  peritonitis  follows,  due  to  the 
escape  of  the  intestinal  contents;  or  the  peritonitis  may  even  be 
due  to  the  infection  from  the  sep- 
tic fluids  in  the  sac. 

Femoral  and  Umbilical  Hernia. 
— -These  forms  of  strangulated 
hernia  require  the  same  modes 
of  procedure  as  the  inguinal  but 
are  likely  to  present  more  obsta- 
cles. In  the  case  of  femoral  her- 
nia, if  complete,  the  pressure 
must  be  made  downward  toward 
the  saphenous  opening  at  first, 
and  then  upward  along  the  fe- 
moral canal. 

In  the  case  of  umbilical  hernia 
the  pressure  must  be  made  toward 
the  umbilical  ring.  Often  the 
Trendelenburg  position  is  helpful. 
The  constant  effort  is  first  to 
empty  the  gut  and  then  reduce  it. 

In  both  these  forms  of  hernia 
the  gut  may  be  enveloped  by  a 
mass  of  omentum  which  may  not 
be  reducible  and  thus  gives  rise  to 
some  doubt  whether  the  gut  has 
been  reduced. 

Operation  for  Strangulated  Hernia :  Inguinal  Hernia. — ^To  repeat, 
as  soon  as  a  hernia  habitually  reducible  becomes  painful  and  irre- 
ducible and  is  accompanied  by  the  signs  of  beginning  prostration, 
regard  it  as  strangulated,  and,  aside  from  the  exceptional  cases 
indicated,  operate  at  once.  Do  not,  wait  for  fecal  vomiting  for  thatis 
the  last  signal  of  exhausted  nature — the  precursor  of  death. 

General  anesthesia  is  usually  necessary,  although  in  some  cases^of 


D 


Fig.  456. — Strangulated  hernia  reduced 
"en  masse."  A.  Upper  end  of  the  loop.  B. 
Neck  of  the  sac  torn  off  and  reduced  with 
the  bowel.  C.  Reduced  loop  still  strangu- 
lated.    D.  Scrotal  portion  of  sac.     {Lejars.) 


6o4 


STRANGULATED   HERNIA 


profound  sepsis  local  anesthesia  with  cocaine  or  stovaine  suffices, 
using  Schleich's  formula  and  injecting  the  various  layers  just  before 
dividing.     No  special  instruments  are  necessary. 

Surgical  Anatomy. — The  special  points  to  be  remembered  are  the 
situation  of  the  abdominal  rings,  the  relations  of  the  external  and 
internal  oblique  and  transversalis  muscles  to  the  inguinal  canal,  and 
the  location  of  the  deep  epigastric  artery. 

The  external  ring  in  the  aponeurosis  of  the  external  oblique  lies 
just  above  the  spine  of  the  pubes.  The  internal  ring  in  the  transver- 
salis fascia  lies  }^  inch  above  the 
middle  of  Poupart's  ligament.  The 
deep  epigastric  artery  passing  verti- 
cally between  the  two  rings,  lies  be- 
tween the  transversalis  fascia  and  the 
peritoneum. 

The  chief  condition  of  operating 
well  is  to  see  and  recognize  what  is  to 
be  divided.  The  coverings  enumer- 
ated with  such  care  by  the  text- 
books will  not  be  distinguished,  but 
there  is  little  danger  of  cutting  into 
the  intestine,  for  before  it  can  be 
reached  the  sac  must  be  opened,  and 
that  is  announced  by  the  escape  of  a 
characteristic  sero-sanguineous  fluid.  The  greatest  injury  to  the 
bowel  is  at  the  site  of  constriction,  which  may  be  at  the  external 
ring,  the  internal  ring,  or  the  neck  of  the  sac. 

The  preparation  of  the  field  of  operation  must  be  painstaking.  The 
pelvis  must  be  shaved  and  scrubbed;  the  adjacent  abdominal  and 
inguinal  regions  and  the  scrotum  must  be  thoroughly  disinfected; 
and  the  penis  after  cleansing  wrapped  in  a  sterile  compress. 

First  Step.  Incision.  Exposure  of  the  Sac. — Begin  with  a  skin  in- 
cision extending  from  the  internal  ring  down  to  the  spine  of  the 
pubes;  if  it  is  a  scrotal  hernia,  down  to  the  middle  third  of  the 
scrotum  (Fig.  461).  Go  directly  through  the  skin  and  layers  of  fat 
to  the  aponeurosis  of  the  external  oblique,  dividing  the  branches  of 
the  superficial  epigastric  artery. 


Fig.  457. — Imperfect  reduction  by 
taxis.  Hernia  outside  the  ruptured 
sac.     {Moullin.) 


HERNIOTOMY 


605 


Expose  the  aponeurosis  thoroughly  and  incise  it  from  one  ring 
to  the  other.  It  is  easily  recognized  by  the  oblique  direction  of  its 
fibers  and  its  shiny  look,  and  will  serve  during  the  operation  as  an 
important  landmark.  The  lips  of  this  wound  should  be  caught  up 
with  forceps,  especially  at  the  external  ring,  to  serve  later  as  a  guide 
in  beginning  repair. 

Once  the  aponeurosis  is  opened  the  sac  is  exposed  and  the  next 
effort  is  to  isolate  it  preparatory  to  its  incision.     Separate  it  from 


Fig.  458. — Strangulated  inguinal  hernia;  primary  incision. 


the  aponeurosis  by  careful  blunt  dissection  around  its  whole  circum- 
ference and  divide  the  remaining  coverings  layer  by  layer  until  the 
sac  is  exposed  and  identified.  Strip  these  coverings  by  blunt  dis- 
section, isolating  the  tumor  up  to  the  internal  ring. 

If  these  layers  are  much  adherent  one  may  be  in  doubt  as  to 
whether  it  is  the  sac  or  the  intestine  which  he  has  exposed.  The 
nature  of  the  blood  supply  will  settle  the  question,  for  the  vessels  of 
the  sac  stand  out  distinctly,  whereas  those  of  the  bowel  are  not 
distinguishable  in  the  uniform  congestion. 


6o6  STRANGULATED  HERNIA 

Second  Step.  Opening  the  Sac. — Catch  a  fold  of  the  sac  with  dis- 
secting forceps  and  cautiously  divide  the  base  of  this  fold  with  scis- 
sors or  scalpel  (Fig.  459).  It  may  be  one  of  the  connective  tissue 
coverings  that  is  opened;  divide  it  the  full  length  of  the  wound  and  so 
proceed  until  finally  the  hernial  sac  itself  is  opened,  which  will  be 
announced  by  a  gush  of  bloody  serum.  Occasionally  this  serum  will 
be  lacking,  the  bowel  being  in  intimate  contact  with  the  sac,  or  even 
adherent  to  it,  but  the  bowel  will  be  recognized  by  its  uniform  color- 
ing and  will  be  separated  as  the  opening  in  the  sac  is  enlarged. 
Cautiously  enlarge  the  opening  till  a  finger  can  be  introduced,  and  on 


Fig.  459. — Opening  the  sac  of  a  strangulated  hernia.     As  soon  as  the  sac  is  opened  a  sero- 

sanguineous  fluid  escapes.     {Guibe.) 


it  as  a  guide,  split  the  sac  close  up  to  its  neck  (Fig.  460).  When  the 
constricting  band  is  reached  slip  the  finger  under  it,  if  possible,  and 
divide  it  completely.  If  too  tight  for  the  finger,  pass  a  grooved 
director  as  a  guide.  In  some  cases  it  may  be  better  to  use  a  herni- 
otomy knife,  but  wherever  possible  avoid  cutting  blindly.  The  con- 
striction must  be  freely  divided  so  that  the  intestine  can  be  readily 
drawn  down  for  inspection.  This  step  is  not  complete  till  that  is 
possible. 

It  may  happen  that  there  is  a  second  constricting  band  higher  up; 
in  such  a  case  the  forceps,  which  should  always  be  attached  to  the 


HERNIOTOMY 


607 


lips  of  the  incision  in  the  sac,  are  useful  in  pulling  it  down  so  that 
what  is  to  be  divided  can  be  seen. 

Third  Step.  Examination  of  the  Intestine. — It  is  of  the  greatest 
importance  that  the  site  of  the  constriction  be  examined,  for  the  chief 
lesions  will  be  found  there.  Pull  the  gut  down  and  observe  the  line 
of  demarcation  between  the  healthy  and  injured  tissue  (Fig.  461). 


Fig.  460. — Dividing  the  constricting  fibers  of  the  strangulated  inguinal  hernia. 

should  be  well  exposed.     {Guibe.) 


The  parts 


One  of  the  several  conditions  will  be  present  and  the  line  of  procedure 
will  depend  upon  the  one  which  is  found. 

I.  The  intestine  is  sound;  that  is  to  say,  it  has  a  uniform,  dark 
violet  color,  most  marked  at  the  site  of  the  constriction  wher^  it 
is  lustrous.  There  is  no  erosion  of  the  serous  covering.  Douching 
the  bowel  with  warm  normal  salt  solution  restores  its  tonicity,  its 
rounded  outline,  and  after  a  few  minutes  it  assumes  a  redder  color 


6o8 


STRANGULATED   HERNIA 


and  is  to  be  returned  to  the  abdominal  cavity.  Following  this  the 
omentum  which  usually  presents  is  to  be  inspected.  If  there  is  a 
considerable  mass  or  if  its  vitality  has  been  compromised  it  should 
be  resected,  using  one  or  several  ligatures  as  the  case  may  require. 
Before  the  stump  is  dropped  back  into  the  peritoneal  cavity  it  must 
be  carefully  inspected  for  bleeding  points  and  should  be  sponged  with 
salt  solution. 

2.  The  intestine  is  slightly  injured;  that  is  to  say,  there  may  be 


Fig.  461. — Examination  of  the  strangulated  loop.     {Veau.) 

several  small  zones  of  erosion  exposing  the  muscular  or  even  the 
mucous  layer.  Bury  these  areas  with  a  few  Lembert  sutures,  repair 
any  injuries  to  the  mesentery,  and  reduce.  If  the  intestinal  loop  is 
long,  a  methodical  procedure  may  be  required  to  prevent  further 
injury  to  tissues  already  compromised.  The  posterior  segment  of 
the  loop  should  be  reduced  first,  as  it  probably  was  the  last  to  come 
down;  in  the  meantime  the  anterior  segment  must  be  carefully  sup- 
ported.    The  least  rudeness  may  result  in  a  tear. 


HERNIOTOMY  609 

3.  The  intestine  is  doubtful;  that  is  to  say,  it  has  a  color  mottled 
gray  and  purple.  It  does  not  recover  its  form  under  the  douching, 
but  stays  collapsed  and  flattened.  Under  these  conditions  it  may 
not  be  possible  to  say  whether  it  is  gangrenous  or  not,  but  it  should 
not  be  reduced. 

Treves,  however,  advises  reduction  under  these  circumstances, 
remarking  (Operative  Surgery,  p.  534,  Vol.  II)  that  whatever  theoret- 
ical objections  to  this  procedure  may  exist,  practice  has  shown  that 
it  may  be  safely  carried  out,  assuming  that  this  applies  to  a  bowel 
which  is  not  actually  gangrenous,  but  in  a  condition  which  may  be 
termed  ''doubtful."  It  is  remarkable  to  what  extent  these  doubtful 
intestines  recover.  The  idea  is  that  the  peritoneal  cavity  is  the 
most  favorable  site  for  recovery. 

If  the  operator  is  inexperienced  and  not  certain  that  he  can  dis- 
tinguish between  the  bowel,  possibly  gangrenous,  and  that  which  has 
actually  lost  its  viability,  he  must  wait.  Wrap  the  loop  in  moist 
gauze,  and  after  twelve  hours  examine  again.  It  may  be  gangrenous 
or  it  may  be  viable,  lustrous,  reddened,  rounded,  and  impels  the  be- 
lief that  it  will  become  normal.  With  that  belief,  reduce  it  slowly 
and  carefully,  breaking  up  the  slight  adhesions  which  have  already 
formed. 

4.  The  intestine  is  obviously  gangrenous;  that  is  to  say,  the  serous 
coat  has  lost  its  luster,  is  blistered  in  spots,  and  can  easily  be  stripped 
off  with  the  fingers;  its  color  is  ashen  or  even  black,  sometimes 
mottled  with  white  patches;  there  is  a  characteristic  odor;  the  tissues 
are  friable;  and  there  may  be  perforations. 

In  this  case  there  is  but  one  of  two  things  to  do:  either  anchor  the 
gut  in  the  wound  and  make  an  artificial  anus,  or  resect  the  bowel. 

There  can  be  no  doubt  that  an  enterectomy  is  the  ideal  procedure 
since  it  eliminates  a  source  of  danger  and  permits  the  radical  cure 
of  the  hernia,  but  it  is  best  not  to  undertake  it  unless  skilled  in  intes- 
tinal suture  (which  for  that  matter  every  doctor  should  know  thor- 
oughly how  to  do)  for  the  time  required  may  aggravate  the  shock 
and  insure  a  fatality;  but  the  first  consideration  is  to  save  life.  (See 
Enterectomy.)  Allison,  of  Omaha  (Jour.  Minn.  State  Med.  Assn., 
Jan.,  1908),  takes  a  different  view:  ''We  believe  primary  end-to-end 
anastomosis  unjustifiable  for,  though  we  escape  shock  and  peritonitis, 
39 


6lO  STRANGULATED   HERNIA 

there  yet  remains  the  danger  of  permanent  obstruction  due  to  circu- 
latory and  septic  changes,  or  a  fatal  paralysis  due  to  distention  and 
toxemia.  Artificial  anus  offers  the  best  way  out.  The  two-stage 
operation  is  safer  than  the  primary." 

If  an  artificial  anus  is  considered  safest,  pull  enough  of  the  gut  out 
to  reach  sound  tissue.  Pass  a  catgut  suture  through  the  abdominal 
wall — that  is,  through  the  aponeurosis  and  the  parietal  peritoneum — 
and  then  through  the  superficial  coats  of  the  bowel,  then  out  through 
the  abdominal  wall  again  to  make  the  letter  "  U. "  Employ  four  such 
sutures  at  the  cardinal  points.  To  the  gangrenous  loop  apply  a  moist 
antiseptic  dressing,  changed  hourly  if  the  intestine  was  perforated. 
If  the  intestine  was  not  perforated,  do  not  open  it  at  once,  but  wait 
a  few  hours  till  adhesions  form. 

It  is  then  to  be  opened  and  the  dressings  must  be  frequently 
changed,  for  the  discharge  will  be  abundant.  Later  the  fistula  may 
gradually  close  of  its  own  accord,  more  and  more  of  the  bowel  con- 
tents passing  by  the  rectum;  or  to  cure  the  fistula  a  diflScult  operation 
may  be  necessary.     (See  Temporary  Artificial  Anus.) 

Fourth  Step.  Ligation  and  A  mputation  of  the  Sac. — In  every  case 
where  the  bowel  may  be  returned  to  the  peritoneal  cavity,  the  treat- 
ment of  the  sac  is  of  the  greatest  importance.  After  the  intestine 
and  omentum  have  been  reduced  proceed  to  disinfect  and  to  dissect 
the  sac,  if  this  has  not  already  been  done,  remembering  that  the 
structures  of  the  cord  may  be  very  intimately  connected  with  it  and 
hard  to  separate.  In  the  strangulated  cases  the  sac  is  usually 
thick,  but  in  the  congenital  cases  it  may  be  thin  and  friable.  It  is 
best  to  begin  by  separating  the  sac  completely  from  the  cord  at  one 
point,  and  then  the  dissection  may  proceed  first  toward  the  scrotum 
and  then  toward  the  peritoneum.  In  some  cases  it  is  best  to  make  an 
incision  through  the  whole  circumference  of  the  sac  being  careful 
not  to  divide  the  main  vessels  of  the  vas,  the  two  portions  being  then 
dissected  separately,  carrying  one  down  to  the  scrotum  if  necessary; 
the  other,  to  the  internal  ring.  Dry  gauze  dissection  is  the  best 
method  of  separating  these  structures,  as  a  rule.  When  the  sac  is 
completely  isolated  the  neck  is  to  be  freed  quite  into  the  abdominal 
cavity,  and  then  a  finger  is  to  be  passed  into  the  opening  that  any 
omental  adhesions  may  be  detected  or  any  concealed  hemorrhage. 


HERNIOTOMY 


6ll 


Next,  the  sac  is  to  be  twisted  and  then  ligated;  or  simple  ligated  as 
high  up  as  possible,  and  amputated. 

In  freeing  the  neck  at  the  internal  ring  the  subperitoneal  fat  is 
usually  seen;  at  this  stage  the  bladder  may  be  injured,  and  the  point 
is  that  any  fatty  tissues  at  the  inner  side  of  the  ring  must  not  be  in- 
cluded in  the  ligature,  for  this  fat  may  conceal  the  bladder. 

In  ligating  the  sac  it  is  best  to  transfix  it  rather  than  use  the  cir- 
ular  ligature.     If  the  sac  has  been  split  so  high  that  the  neck  cannot 


Fig.  462. — Repair  after  relief  of  strangulated  inguinal  hernia.    Suture  of  conjoined  tendon 
to  Poupart's  ligament.     C,  Cord;     E,  epigastric  artery;  PC,  internal  oblique.     {Guibe.) 


be  defined,  then  the  upper  end  of  the  peritoneal  wound  should  be  re- 
paired with  a  few  stitches  so  as  to  reconstruct  the  neck  which  is  then 
to  be  ligated. 

Fifth  Step. — This  will  depend  upon  the  condition  of  the  patient. 
If  his  condition  is  serious,  it  is  sufl&cient  rapidly  to  reunite  the  apon- 
eurosis and  repair  the  skin  incision.  If  a  little  more  time  may  be 
used,  proceed  to  do  the  radical  cure  (Fig.  462).     Unless  this  is  done 


6l2  STIL\XGULATED   HERNIA 

recurrence  is  almost  certain,  but  the  operator  cannot  be  held  respon- 
sible for  that.     In  the  urgent  cases  it  s  sufficient  to  have  saved  a  ife. 

Whether  the  radical  operation  is  attempted  or  not,  employ  drain- 
age.    The  dressing  must  be  carefully  applied. 

Subsequent  Treatment. — The  patient  must  have  no  food  for  twenty- 
four  hours.  It  may  be  necessary  to  employ  salt  solution  freely.  A 
little  ice  may  be  given  to  quench  the  thirst.  At  the  end  of  twenty- 
four  hours  begin  with  small  quantities  of  milk.  Change  the  dress- 
ings the  second  day,  or  sooner  if  much  soiled.  On  the  third  or  fourth 
day  give  a  laxative.  Remove  the  drain  on  the  fifth.  Remove  the 
sutures  on  the  eighth  or  ninth.  Peritonitis  may  supervene  if  the 
gangrenous  areas  have  not  been  properly  treated. 

POSSIBLE  COMPLICATIONS  IN  THE  OPERATION 

In  the  operation  just  described,  the  ordinary  difficulties  are  indi- 
cated. But  there  are  others,  rarer,  which  may  arise  to  disconcert  the 
casual  operator  not  forewarned.  The  actual  operation  is  always 
easier  if  one  has  in  mind  all  the  possibilities.  There  may  be  unex- 
pected adhesions;  there  may  be  anomalies  with  resepct  to  the  sac  or 
its  contents,  or  there  may  be  unsuspected  conditions  produced  by 
attempts  at  taxis. 

Adhesions  must  be  anticipated  when  the  hernia  is  large  and  has 
been  for  a  long  time  irreducible,  and  under  these  circumstances 
special  precautions  must  be  taken  not  to  wound  the  bowel  in  opening 
the  sac.  The  adhesions  if  recent  and  soft  may  be  broken  up  with  the 
finger  or  grooved  director  keeping  in  close  contact  with  the  sac  so 
as  to  avoid  the  bowel. 

If  the  adhesions  are  old  and  the  union  between  the  bowel  or  omen- 
tum with  the  sac  firm  and  fibrous,  it  will  be  necessary  to  divide  them 
with  scalpel  or  scissors,  but  this  is  a  procedure  requiring  patience 
and  a  delicate  touch.  If  necessary,  long,  band-like  adhesions  may  be 
divided  between  forceps  and  subsequently  ligated. 

If,  following  the  decortication,  the  raw  surfaces  ooze  to  any  serious 
extent,  apply  hot,  moist  compresses  for  a  moment,  and  either  this 
will  check  the  bleeding  or  at  least  reveal  the  site  of  the  larger  vessels 
to  be  caught  up  with  forceps.     Usually  a  few  apphcations  of  the  hot 


COMPLICATIONS   IN  HERNIOTOMY  613 

compresses  will  entirely  suppress  the  oozing,  or  at  least  to  such  degree 
as  not  to  contra-indicate  reduction;  for  when  the  bowel  is  no  longer 
bent  and  the  circulation  no  longer  interfered  with  the  oozing  will 
spontaneously  cease. 

But  it  is  chiefly  injury  to  the  bowel  which  is  to  be  feared,  not  so 
much  because  the  rent  may  be  diificult  to  repair  as  that  some  of  the 
septic  contents  of  the  bowel  may  escape. 

If  the  adhesions  cannot  he  broken  up  the  only  thing  left  is  to  remove 
the  source  of  the  strangulation  and  leave  the  bowel  outside.  Occa- 
sionally it  will  be  found  that  the  source  of  strangulation  is  in  some 
of  the  adhesions  rather  than  the  rings,  or  the  neck  of  the  sac;  or, 
again,  so  much  scar  tissue  in  the  bowel  wall  leaves  it  inert  and  para- 
lyzed. All  these  difl&culties  are  more  likely  to  occur  in  the  neglected 
cases. 

A  hernia  of  the  cecum  or  sigmoid  may  present  difficulties  depend- 
ing upon  adhesions.  It  must  be  remembered  that  these  two  portions 
of  the  large  intestine  are  not  completely  invested  by  peritoneum;  and, 
in  consequence,  it  may  come  to  pass  that  when  they  slide  down 
through  the  inguinal  canal  a  point  is  reached  where  a  part  of  the  bowel 
is  outside  the  hernial  sac,  and  this  surface  acquires  adhesions  to  the 
scrotal  tissues.  In  such  cases  these  adhesions  cannot  be  divided  for 
fear  of  wounding  important  branches  of  the  mesenteric  arteries,  so 
that  to  effect  reduction  a  special  procedure  must  be  employed. 

In  the  first  place,  when,  on  opening  the  hernial  sac,  these  parts 
of  the  large  bowel  are  recognized,  the  neck  of  the  hernia  must  be 
freelv  incised  and  the  abdominal  walls  as  well.  In  fact,  one  does 
what  Lejars  calls  a  hernio-laparotomy . 

Next  the  hernial  sac  is  separated  from  the  spermatic  cord  and 
then  an  effort  is  made  to  reduce  the  hernia  en  masse,  returning,  if 
possible,  the  bowel  and  the  peritoneal  prolongation  at  the  same  time. 
It  will  be  a  slow  and  tedious  process.  It  is  greatly  aided  by  the  Tren- 
delenburg position.  If  the  attempt  fails,  an  artificial  anus  is  the  last 
resort. 

Among  the  anomalies  of  the  sac  which  may  bother  the  operator  are 
diverticula  and  double  compartments.  One  may  open  into  what  ap- 
pears to  be  the  hernial  sac  and  find  it  empty.  In  encysted  hernia 
the  processus  vaginalis  may  be  filled  with  fluid  which  surrounds  the 


6 14  STRANGULATED   HERNIA 

true  hernial  sac.  A  little  study  of  the  conditions  will  lead  one  to  go 
ahead  and  find  and  open  the  true  hernial  sac. 

The  hernial  sac  may  push  in  between  the  peritoneum  and  the 
muscular  layers,  bulging  toward  the  iliac  fossa  or  the  bladder.  This 
is  the  pro-peritoneal  hernia,  and  when  it  becomes  strangulated  it  is  not 
likely  a  diagnosis  will  be  made.  Yet  the  presence  of  a  tumor  in  the 
inguinal  region  and  the  signs  of  intestinal  obstruction  will  demand  an 
operation  and  again  a  hernio-laparotomy  is  indicated.  The  site  of 
strangulation  is  located  and  the  bowel  treated  as  in  the  ordinary 
form  of  strangulated  hernia. 

In  the  interstitial  form  of  hernia  great  difficulties  may  arise.  The 
incision  is  likely  to  be  quite  different  from,  the  ordinary  since  it  fol- 
lows the  long  axis  of  the  tumor.  Once  the  hernial  sac  is  exposed  it 
must  be  freed  from  its  adhesions  to  the  muscles.  The  neck  of  the  sac 
corresponds  to  the  internal  ring,  and  if  that  is  the  site  of  constriction 
it  must  be  divided  by  cutting  outward.  The  deep  epigastric  artery 
lies  to  the  inner  side. 

After  the  bowel  is  reduced  and  the  sac  ligated,  the  break  in  the 
abdominal  wall  must  be  sutured,  repairing  the  opening  in  each  layer 
separately. 

The  contents  of  the  hernial  sac  may  be  abnormal.  At  some  time 
or  other  each  of  the  abdominal  organs  except  the  pancreas  have  been 
found  herniated.  It  is  the  bladder  which  most  often  gives  rise  to 
trouble. 

It  may  be  in  the  sac  and  appear  as  a  second  "  sac  "  when  the  hernial 
sac  is  opened.  It  presents  as  a  rounded,  reddish  tumor,  perhaps  as 
large  as  a  hen's  egg.  Such  a  tumor  should  never  be  opened  on  sus- 
picion, but  a  careful  effort  must  be  made  to  locate  its  limits  by  blunt 
dissection.  The  fact  that  it  leads  down  to,  and  behind,  the  pubes 
clears  up  any  doubt.  It  is  to  be  reduced  in  the  same  manner  as  the 
intestine.  In  other  instances  it  is  without  the  sac,  lying  to  the  inner 
side  of  its  neck  and  is  perhaps  intimately  connected  thereto.  It  may 
be  mistaken  for  a  thickened  portion  of  the  sac  or  an  adherent  mass  of 
fatty  tissue. 

If  it  is  opened  into,  the  escape  of  urine  and  the  evidence  to  the  ex- 
amining finger  of  a  large  mucous-lined  cavity  reveals  the  nature  of  the 
accident  and  imposes  immediate  repair. 


APPENDIX   IN   HERNIOTOMY  615 

A  large  hernia,  easily  reducible,  or  one  whose  size  diminishes,  fol- 
lowing urination  or  the  use  of  the  catheter  suggests  hernia  of  the  blad- 
der; but,  unfortunately,  these  signs  are  not  available  in  strangula- 
tion. In  every  herniotomy  the  danger  of  wounding  the  bladder  must 
be  kept  in  mind. 

Another  point  Lejars  makes :  One  may  expose  a  thin- walled  trans- 
parent cyst  at  the  inner  side  of  the  neck  of  the  sac,  and  unwittingly 
open  it  only  to  find  oneself  working  into  the  bladder.  This  trans- 
parent cyst,  in  nowise  resembling  the  bladder,  is  due  to  a  hernia  of  the 
mucosa  of  the  bladder  between  the  fibers  of  the  muscularis. 

Following  the  separation  of  the  bladder  from  the  hernial  sac  the 
urine  may  be  bloody  for  a  day  or  two.  This  hematuria  is  of  little 
moment  and  soon  clears  up. 

If  the  bladder  is  wounded  its  repair  must  precede  everything  else. 
As  soon  as  the  injury  is  discovered,  pack  around  the  site  with  sterile 
gauze,  catch  the  edges  of  the  wound  with  small  forceps  and  suture, 
uniting  the  mucosa  first  with  a  continuous  catgut  suture,  and  the 
muscular  coat  with  interrupted  sutures,  accurately  applied;  a  third 
line  connects  the  superficial  tissues. 

The  appendix  may  be  found  in  the  hernial  sac,  either  inflamed  or 
normal.  If  the  latter,  it  is  to  be  removed  in  the  ordinary  way  unless 
time  presses,  in  which  case  one  must  be  satisfied  with  reducing  it. 

If  the  symptoms  of  strangulation  arise  in  consequence  of  an  in- 
flamed and  herniated  appendix,  they  may  differ  somewhat  from  those 
ordinarily  observed.  There  will  be  the  same  tendency  to  collapse,  the 
vomiting,  the  tympanites;  but  constipation  may  not  be  complete,  and 
the  hernial  tumor,  in  addition  to  being  swollen  and  painful,  may  be 
reddened  and  edematous. 

No  one  should  think  of  taxis  under  these  circumstances:  as  im- 
mediate operation  is  indicated.  Regarding  these  grave  cases,  Kelly 
says  (Vermiform  Appendix  and  its  Disease,  page  793)  where  there  is 
suppuration  in  the  sac  it  must  be  drained,  and  here  as  well  as  in  the 
cases  where  there  is  gangrene  in  the  appendix,  resulting  from  strangu- 
lation, the  utmost  care  must  be  observed  in  handhng  the  diseased 
tissues  in  order  to  avoid  inoculating  the  peritoneal  cavity.  If  the  dis- 
eased portion  is  found  to  extend  up  into  the  peritoneal  cavity,  the 


6l6  STEANGULATED   HERNIA 

operator  must  at  all  hazards  discover  the  upper  limits  of  the  infection 
and  resect  the  bowel  in  its  healthy  portion. 

Moreover,  he  must  do  this  with  the  least  possible  manipulation 
and  traction  upon  the  parts,  preferably  by  enlarging  the  abdominal 
opening  in  the  direction  of  the  inguinal  canal  while  protecting  the 
healthy  regions  and  keeping  the  disease  well  isolated  by  abundant 
gauze  compresses. 

When  infection  extends  still  further  up  into  the  abdomen  an  even 
wider  incision  must  be  made,  if  necessary,  in  the  form  of  an  inverted 
X  in  order  to  provide  abundant  drainage  after  removal  of  the  disease. 
In  such  cases  the  cure  of  the  hernia  becomes  a  matter  of  secondary 
consideration  to  be  taken  up  after  recovery. 

In  a  case  seen  by  the  author  the  patient  was  an  old  woman,  for 
vears  affected  with  an  inguinal  hernia  usuallv  easilv  reduced.  It 
became  strangulated,  presenting  a  hard  painful,  inflamed  lump, 
the  size  of  a  hen's  egg. 

She  was  nauseated,  in  much  pain,  slightly  febrile,  only  slightly 
tympanitic,  and  enemas  were  effective  in  moving  the  bowel.  The 
operation  revealed  a  strangulated  appendix  and  nothing  more.  It 
was  well  exposed  and  resected  without  difficulty  and  with  complete 
relief.  In  repairing  the  abdominal  wall  the  sutures  were  passed 
through  the  lower  edge  of  the  external  oblique,  through  Poupart's 
ligament  and  out  through  the  upper  edge  of  the  aponeurosis,  com- 
pletely obliterating  the  inguinal  canal.  This  combination  is  unusual 
— an  old  woman,  an  inguinal  hernia  and  a  strangulated  appendix. 

McEwen  (London  Lancet,  June  i6,  1906)  reports  a  case  in  which 
the  patient,  a  man  of  sixty- two,  presented  himself  for  an  opera- 
tion for  strangulated  hernia.  Two  weeks  previously  his  hernia  (of 
twelve  years'  standing)  had  begun  to  give  him  pain,  which  had  gradu- 
ally increased. 

A  large  pyriform  tumor  occupied  the  right  inguinal  region  and 
the  scrotum,  which  was  much  inflamed.  The  mass  was  dull  on  per- 
cussion, there  was  no  impulse  on  coughing,  and  it  was  irreducible. 
On  opening  the  sac  the  hernia  was  found  to  consist  of  the  appendix, 
held  in  position  by  a  pin  protruding  through  its  wall.  There  was  no 
abscess  formation,  yet  it  was  not  deemed  advisable  after  removal  of 
the  appendix  to  proceed  with  the  radical  cure. 


FEMORAL   HERNIA  617 

Regarding  these  unusual  conditions,  Lejars  remarks  that  in  be- 
ginning an  operation  for  strangulated  hernia  we  should  expect  every- 
thing and  be  surprised  at  nothing;  laying  aside  for  the  moment  all 
theoretical  discussions  and  applying  ourselves  to  the  chief  indication, 
not  deeming  our  work  complete  until  the  bowel  is  properly  reduced 
and  lost  to  view  in  the  abdominal  cavity. 

Oliver,  of  Indianapolis  (Ind.  Med.  Jour.,  March,  1908),  reports  a 
case  in  which  the  hernia  had  grow^n  to  remarkable  proportions  ex- 
tending as  low^  as  the  knee.  The  mass  had  long  been  irreducible. 
The  patient  was  a  butcher  of  about  fifty  years  of  age.  Following  a 
heavy  meal  of  ''pigs'  feet"  and  a  lift,  his  hernia  suddenly  became 
painful  and  he  experienced  the  sensation  of  something  giving  way; 
symptoms  of  strangulation  in  mild  form  gradually  developed;  taxis 
being  out  of  the  question,  immediate  operation  was  practised.  On 
opening  the  hernial  sac  it  developed  that  its  content  w^as  the  stomach 
in  its  entirety,  but  no  gut  was  present.  With  great  difficulty  it  was 
reduced.  The  patient's  condition  did  not  permit  of  any  further 
manipulation,  and  shortly  afterward  he  succumbed.  Oliver  ex- 
presses the  opinion  that  the  stomach  had  been  forced  down  into  the 
sac  by  the  strain,  replacing  the  gut. 

Strangulated  Femoral  Hernia 

Operation  is  even  more  urgent  in  the  case  of  strangulated 
femoral  hernia  than  in  strangulated  inguinal  hernia.  Gangrene 
is  likely  to  develop  earlier,  and  taxis  is  all  the  more  ineffectual  by 
reason  of  the  anatomical  arrangement.  Especially  must  one  be 
on  his  guard  in  the  case  of  small  hernia  for  the  ring  is  un\ielding. 
It  is  essential  to  have  the  anatomy  in  mind  to  understand  this  and 
especially  in  order  to  operate  without  embarrassment. 

Surgical  Atiatomy. — Poupart's  ligament  stretches  across  the  front 
of  the  pelvic  region  from  the  anterior  superior  spine  of  the  iUum  to 
the  spine  of  the  os  pubis.  The  space  between  this  band  and  the 
ramus  of  the  pubis  is  occupied  by  several  structures — from  without 
inward,  the  iliacus  and  psoas  muscles  on  their  way  to  the  lesser 
trochanter,  the  crural  nerve,  the  femoral  artery  and  vein,  the  femoral 
canal,  and  Gimbernat's  ligament. 


6i8 


STRANGULATED  HERNIA 


Gimbernat's  ligament  is  a  firm  triangular  fascia  with  its  base 
directed  outward  and  abutting  the  femoral  canal. 

The  femoral  sheath,  a  prolongation  of  the  iliac  fascia,  encloses  the 
femoral  vessels.     In  the  thigh  it  fits  closely  about  the  vessels. 


Fig.  463. — Relations  of  the  neck  of  a  femoral  hernia  under  Poupart's  ligament.  Beneath 
Poupart's  ligament  from  without  inward;  the  iliacus,  the  psoas,  the  femoral  artery,  the  vein, 
the  hernia,  concealing  Gimbernat's  ligament  which  is  between  its  neck  and  the  pubes. 
(Moullin.) 

In  the  groin  the  sheath  is  more  capacious  so  that  there  is  a  space 
left  between  its  inner  wall  and  the  femoral  vein.  This  space  consti- 
tutes the  femoral  canal.  The  femoral  canal  is,  therefore,  conical  in 
shape  with  its  base  above  and  its  apex  below  where  the  sheath  gets 
in  contact  with  the  femoral  vein.     The  circumference  of  the  base 


HERNIOTOMY.      FEMORAL  HERNIA  619 

constitutes  the  femoral  ring  which  is  bounded  internally  by  the  base 
of  Gimbernat's  ligament;  above,  by  Poupart's  ligament;  below,  by 
the  ramus  of  the  pubes;  externally,  by  the  femoral  vein.  The  narrow 
orifice  bounded  by  these  structures  is  the  usual  site  of  strangulation 
of  a  hernia  descending  along  this  slender  channel. 

It  is  Gimbernat's  ligament  whose  sharp  edge  is  most  likely  to 
shut  off  the  circulation  of  a  loop  of  intestine  bulging  past  it  and  which 
is  most  likely  to  cut  into  or  bruise  the  bowel  in  efforts  at  taxis  (Fig. 

463). 

In  other  cases  the  hernia  descending  lower  finds  the  direction 

of  least  resistance  toward  the  surface  and  bulges  out  through  the 

saphenous  opening  and  the  cribriform  fascia. 

Operation. — If  the  operation  is  done  early  before  complications, 
such  as  gangrene,  have  arisen,  the  operation  for  strangulated  femoral 
hernia  is  simple  and  without  special  danger.  Begin  by  disinfecting 
the  whole  field;  the  inner  surface  of  the  thigh,  the  groin,  the  abdomen, 
the  genitals. 

The  incision  may  be  vertical  following  the  axis  of  the  tumor,  or 
oblique,  below  and  parallel  to  Poupart's  ligament;  Lejars  prefers  the 
latter,  claiming  that  it  gives  freer  access  to  the  femoral  ring,  facili- 
tates the  dissection  of  the  sac  and  the  procedures  in  the  radical  cure. 

The  vertical  incision  is  probably  better  for  large  and  lobulated 
hernia  which  extend  well  below  Poupart's  ligament.  But  whatever 
incision  is  employed  must  be  of  ample  length. 

The  incision  traverses  the  skin,  and  then  a  fatty  layer  through 
which  ramify  a  number  of  veins  tributary  to  the  long  saphenous. 
Having  divided  this  layer,  the  sac  is  exposed;  or,  at  least,  the  fatty 
envelope  in  which  so  often  it  is  enclosed — a  collection  of  fat  which 
at  times  amounts  to  a  veritable  lipoma.  The  hernial  sac  lies  im- 
mediately beneath  this  fat — sometimes  in  thin  subjects  immediately 
beneath  the  skin — and  presents  itself  in  divers  aspects.  Usually 
it  looks  like  a  tense  and  reddish  cyst;  often  it  is  lobulated 
(Fig.  464). 

Second  Step. — Isolate  the  sac.  Proceed  to  separate  it  from  the 
adjacent  tissues  by  blunt  dissection,  peeling  it  out  with  the  fingers, 
and  disengaging  it  quite  up  to  the  neck.     It  is  essential  for  the  later 


620 


STRANGULATED   HERNIA 


steps  of  the  operation  that  this  be  thoroughly  done  and  is  complete 
when  Poupart's  and  Gimbernat's  ligaments  are  well  in  view. 

This  dissection  of  the  sac  takes  less  time  than  one  might  expect 
and  is  greatly  facilitated  if  one  is  able  to  find  a  line  of  cleavage  be- 
tween the  tissues.  Sometimes  bursae  intervene  between  the  sac 
and  adjacent  tissues  and  favor  a  rapid  separation. 

Third  Step. — Open  the  sac;  examine  the  contents.  Once  the  hernial 
tumor  is  well  exposed  up  to  the  constricting  ring,  cautiously  incise 
the  sac.  Caution  is  required  because  often  it  is  difficult  to  know 
when  one  has  penetrated  the  sac  and  an  adherent  intestine  may  be 


Fig.  464. — Strangulated  femoral  hernia:  primary  incision  exposing  hernia  and  Poupart's 

ligament.      (Guibe.) 


wounded.  In  this  form  of  hernia  the  true  sac  may  be  covered  by 
a  cyst,  which  may  be  filled  by  bloody  serum  and  thus  simulate  the 
appearances  of  the  hernial  sac.  A  moment's  examination,  however, 
shows  that  it  is  a  small  closed  cavity  without  communication  with 
the  abdomen.  The  layers  are  to  be  cautiously  divided  one  by  one 
until  the  sac  is  opened  into  and  the  opening  enlarged. 

Catch  up  the  lips  of  the  wound  of  the  sac  and  examine  its  contents. 
Usually,  in  this  form  of  strangulated  hernia,  one  will  see  a  small  loop 
of  intestine,  darkened,  tense,  and  tightly  constricted.  Occasionally 
along  with  the  omentum  there  may  be  several  loops  of  small  intes- 
tine, or  the  cecum,  or  the  sigmoid  flexure.     Irrigate  the  cavity  and 


HERNIOTOMY.       FEMORAL   HERNIA 


621 


its  contents  with  normal  salt  solution  and  prepare  to  relieve  the 
constriction. 

Fourth  Step. — Relieve  the  constriction.  The  first  effort  should  be  to 
relieve  the  strangulation  by  stretching  the  offending  fibers,  to  this 
end  introducing  a  finger,  if  possible,  into  the  ring  along  the  inner  side 
of  the  hernia. 

Oftentimes  the  pressure  thus  exerted  will,  with  a  little  effort, 
stretch  and  enlarge  the  opening  sufficiently  to  relieve  the  constriction 
and  to  permit  the  necessary  manipulation  of  the  bowel. 

It  may  not  be  possible  to  introduce  a  finger,  and  then  one  must 
resort  to  incision.     To  accomplish  this  a  grooved  director  may  be 


Fig.  465. — Strangulated  femoral  hernia:  closing  the  femoral  canal.     Note  manner  in  which 
sutures  are  passed,  avoiding  femoral  vein  at  outer  border. 

slipped  up  alongside  the  bowel  and  the  fibers  divided  with  scissors  or 
bistoury;  or  if  the  fibers  are  in  plain  view,  as  they  should  be,  they  may 
be  nicked  with  the  point  of  the  bistoury  and  when  room  is  thus  made 
the  finger  may  be  introduced  as  before.  The  use  of  the  herniotomy 
knife  should  be  reserved  for  exceptional  cases,  where  the  subject  is 
fleshy  and  the  obstruction  beyond  reach  and  very  tight. 

But  whatever  method  may  be  practised,  one  must  keep  to  the 
inside,  cutting  inward  or  upward  to  avoid  injury  to  the  bowelor  the 
femoral  vein. 


62  2  STRANGULATED   HERNIA 

When  the  obstruction  is  removed  pull  the  bowel  down  and  ex- 
amine it.  If  it  is  suspicious  or  gangrenous,  treat  it  after  the  manner 
indicated  under  Strangulated  Inguinal  Hernia. 

If  it  is  sound,  reduce  it;  liberate  the  sac  around  the  femoral  ring, 
ligate  and  resect  it;  and  close  the  femoral  canal.  The  after-treatment 
is  the  same  as  for  inguinal  hernia. 

Fifth  Step. — Close  the  femoral  ring.  Two  circular  sutures  acting 
when  tied  after  the  manner  of  a  purse  string  are  to  be  passed: 
one  including  the  pectineal  fascia  and  the  fascia  of  the  external 
oblique;  the  second,  more  deeply  placed,  including  the  pectineal 
fascia,  Poupart's  ligament  and  Gimbernat's  ligament. 

Avoid  wounding  the  femoral  vein,  which  lies  in  contact  with  the 
outer  border  of  the  femoral  ring.  When  these  sutures  are  tied  the 
external  oblique  is  pulled  down  into  close  contact  with  the  pec- 
tineal fascia  and  the  canal  obliterated  (Fig.  465). 

It  remains  to  be  said  that  in  exceptional  cases  it  may  be  necessary, 
in  order  to  see  what  to  do,  to  divide  Poupart's  ligament;  or,  in  the 
male  where  the  cord  is  to  be  avoided,  to  make  another  incision  along 
the  inguinal  canal,  exposing  the  neck  of  the  hernia;  or,  following  the 
method  of  Tuffier,  to  open  directly  into  the  peritoneal  cavity  through 
the  inguinal  canal. 

Strangulated  Umbilical  Hernia 

A  strangulated  umbilical  hernia  is  peculiar  in  two  or  three  respects. 
It  is  likely  to  be  deceptive  in  that  the  characteristic  symptoms  of  in- 
testinal obstruction  may  be  wanting.  The  site  of  strangulation  is 
more  likely  to  be  in  the  sac  than  at  the  umbilical  ring.  But  because 
the  absolute  signs  of  obstruction  are  absent  and  because  the  opening 
at  the  umbilicus  seems  patent,  one  has  no  excuse  to  delay  when  an  old 
and  long  irreducible  rupture  becomes  suddenly  painful,  with  vomiting 
and  partial  constipation. 

Too  often,  as  Lejars  says,  we  caU  these  attacks  with  comparatively 
mild  onset,  pseudo-strangulation;  and  so  the  case  drifts  along  while 
septic  absorption  goes  on  insidiously  but  surely.  From  day  to  day 
the  circulation  grows  weaker,  the  abdomen  more  tympanitic,  the 
vomiting  more  pronounced,  until  the  vital  forces  are  practically  over- 


STRANGULATED   UMBILICAL   HERNIA 


623 


come,  at  which  time,  too  late,  it  is  decided  to  operate.  The  expect- 
ant treatment  and  repeated  taxis  in  these  cases  are  merely  methods 
of  ''losing  time." 

Following  such  practice  one  can  confidently  expect  a  large  per- 
centage of  fatalities,  though  one  should  not  hesitate  to  operate  even 
in  the  face  of  such  odds.  Operating  early,  one  may  give  assurance  of 
excellent  results.  To  quote  Lejars  again,  it  is  not  the  operation 
which  is  to  be  feared:  it  is  the  delay. 

Operation.— Careful  disinfection  of  the  whole  abdominal  wall;  a 
prudent  and  cautious  anesthesia.     The  incision  may  follow  the 


Fig.  466. — Strangulated  umbilical  hernia:  incision  skirting  the  base  of  the  tumor. 
The  peritoneum  opened  in  the  same  line  exposes  the  omentum  and  bowel.  Omentum 
clamped  and  divided  along  dotted  line.     {Guibe.) 


median  line  extending  well  beyond  the  tumor  above  and  below  (Fig. 
466) ;  or  in  the  case  of  a  large  tumor,  may  consist  of  two  semilunar 
incisions  on  either  side  of  the  middle  line  which  enables  one  to  get  rid 
of  redundant  tissue. 

In  either  case  the  incision  must  not  go  deep  from  the  first  for 
often  the  skin  is  quite  thin,  often  adherent  to  the  sac,  and  it  is  easy 
to  go  directly  into  the  sac.     By  reason  of  this  adhesion  at  the  center 


624 


STRANGULATED   HERNIA 


of  the  tumor,  begin  the  dissection  at  the  poles  of  the  incision  and 
work  toward  the  center. 

As  soon  as  the  skin  is  detached  proceed  to  isolate  the  tumor,  if 
possible,  up  to  its  point  of  emergence.  It  may  not  be  practicable 
if  the  tumor  is  large  and  lobulated  to  take  the  time,  and  in  such  a 
case  the  sac  may  be  opened  into  at  once. 

Second  Step. — Open  the  sac.  Detach  the  o?ne?itum.  Nearly  always 
on  first  opening  the  sac  only  omentum  can  be  seen.  It  completely 
envelops  the  bowel.     The  fingers  are  gently  insinuated  between 


Fig.  467. — Strangulated  umbilical  hernia:  the    sac^laid  open  to  relieve  the  strangulation 

and  free  the  bowel.      (Guibe.) 

the  omentum  and  the  sac,  and  the  adhesions  progressively  broked 
down.  Wherever  a  lobule  of  omentum  is  found  encysted  in  a  diver- 
ticulum of  the  sac,  it  must  be  dissected  out  in  the  same  manner. 
Finally  the  entire  omentum  will  be  freed,  may  be  lifted  up,  and  the 
gut  exposed.  In  other  cases  divide  the  omentum  as  indicated  in 
Fig.  489. 

Irrigate  both  the  bowel  and  omentum  with  normal  salt  solution, 
wipe  with  sterile  gauze  and  examine  the  bowel  carefully  to  see  that 
there  is  no  danger  of  perforation  and  of  soiHng  of  the  peritoneum  in 
the  process  of  reduction. 


STRANGULATED   UMBILICAL   HERNIA 


625 


Third  Step. — Relieve  the  strangulation.  Oftentimes  the  umbilical 
ring  may  need  only  to  be  stretched  a  little  to  permit  the  free  manipu- 
lation of  the  bowel;  again,  it  may  be  necessary  to  divide  the  con- 
stricting fibers.  This  may  be  most  readily  accomplished  by  pulling 
down  the  omentum,  slipping  a  finger  between  it  and  the  upper  part 
of  the  ring  to  the  left  of  the  middle  line.  If  this  nick  does  not  give 
sufficient  release,  repeat  on  the  opposite  side. 


Fig.  468. — Strangulated  umbilical  hernia:  completing  section  of  base  of  the  tumor.     (Guibe.) 


When  the  necessary  room  is  obtained,  ligate  the  omentum,  resect 
it,  cleanse  the  stump  and  reduce  it  that  there  may  be  nothing  to 
interfere  with  the  treatment  of  the  bowel.  If  the  omentum  has  been 
resected  in  the  manner  indicated,  the  tumor  mass  may  be  laid  wide 
open  in  order  that  the  strangulated  loops  may  be  well  exposed  and 
freed   (Fig.  467). 

Following  this  the  incision  is  continued  around  the  base  of  the 
tumor,  completely  removing  it  and  leaving  the  various  layers  of 
the  abdominal  wall  exposed  ready  for  repair  (Fig.  468). 

With  respect  to  the  bowel,  the  same  principle  of  treatment  holds 
good  as  in  inguinal  hernia.  Repair  any  slight  defects  or  abrasions. 
40 


626 


STRANGULATED   HERNIA 


If  its  viability  is  doubtful,  keep  it  under  observation  for  a  few  hours. 
If  gangrenous,  either  anchor  it  in  the  wound  and  make  an  artificial 
anus  or  do  an  enterectomy. 

It  may  be  that  in  very  large  umbilical  hernia  it  is  better  to  modify 
the  procedure^  following  the  plan  of  ^layo  and  others,  in  order  to 
gain  time. 

A  transverse  elliptical  incision  is  made  around  the  tumor  at  such 
distance  from  the  center  that  the  redundant  tissue  shall  be  removed. 
Cut  down  to  the  sac.  Next  cautiously  open  the  sac  following  the 
skin  incision.     Apply  several  forceps  to  the  edges  of  the  sac  so  that  it 


Fig.  469. — Peritoneum  closed  and  first  layer  of  mattress  sutures  for  fascia  passed,     {Guibe.) 


is  constantly  under  control.  Detach  the  omentum,  freeing  it  com- 
pletely up  to  the  neck  of  the  sac.  Ligate  and  resect  it,  and  working 
along  its  under  surface  free  it  from  the  bowel.  Once  detached  the 
paquet  of  omentum  carries  with  it  a  segment  of  the  skin  and  of  the 
sac. 

The  bowel  is  next  treated  and  reduced.     This  may  not  be  as  easily 
done  as  said,  for  there  are  several  circumstances  under  w^hich  the 


STRANGULATED   UMJ3ILICAL  HERNIA 


627 


bowel  may  push  out  and  threaten  eventration.     But  no  effort  should 
be  made  to  push  l^ack  the  rebellious  loops  en  masse. 

Proceed  at  once  to  enlarge  the  opening,  lift  up  the  edges  of  the 
peritoneum  by  the  attached  forceps  and  cover  the  bowel  with  a  wide 
compress,  tucking  its  edges  under  the  belly  walls  on  all  sides,  as  de- 
scribed elsewhere.  As  little  by  little  the  bowel  is  returned  the  edges 
of  the  compress  are  slipped  farther  under.  When  reduction  is  com- 
plete the  compress  is  left  in  situ  until  the  sutures  are  placed. 


Fig.  470. — Second    layer   of   mattress   sutures   completing   the  overlapping  of 

the  fascia.  (Guibe.) 


Fourth  Step. — The  mode  of  repairing  the  abdominal  wall  varies 
with  the  circumstances  and  the  operator,  and  depends  upon  how 
much  time  one  may  take.  When  the  condition  of  the  patient 
imposes  great  haste  it  must  suffice  to  pass  interrupted  sutures 
through  the  whole  thickness  of  the  belly  wall  and  draw  the  edge  of 
the  wound  together  so  that  the  peritoneal  edges  point  out  and  the 
two  serous  surfaces  are  thus  brought  into  contact.  Before  the  last 
suture  is  tied  the  compress  is  removed;  and  finally  a  continuous  su- 
ture will  complete  the  reunion. 

If  more  time  is  available,  the  sac  is  trimmed  down  to  the  perito- 
neum proper  and  its  edges  sutured  as  after  a  laparotomy.  The 
sheaths  of  the  recti  muscles  are  opened  up  and  the  inner  border  of  each 
muscle  exposed.    The  two  sides  are  then  brought  in  contact  and  three 


628  STRANGULATED  HERNIA 

tiers  of  sutures  applied;  one  uniting  the  deep  layer  of  the  rectal  sheath 
to  its  fellow  of  the  opposite  side;  the  second  uniting  the  two  muscles; 
the  third  uniting  the  two  superficial  layers  of  the  sheath  overlapping 
and  securing  them  by  mattress  sutures  (Figs.  469  and  470). 


Fig.  471. — Umbilical  hernia:  dissection  of  sac.      (Mayo.) 

Finally  the  excess  of  subcutaneous  fat  is  trimmed  away  and  the 
skin  sutured.  The  usual  dressing  is  appHed,  held  in  place  by  a  wide 
binder,  and  the  after-treatment,  already  indicated,  is  instituted. 

Figs.  471  and  472  show  the  manner  in  which  ]\rayo  perfects  the 
radical  cure. 

Obturator  Hernia. — A  strangulated  obturator  hernia  is  rare,  yet 
it  is  to  be  thought  of  and  ruled  out  before  opening  the  abdomen  for 


STRANGULATED    OBTURATOR   HERNIA 


629 


intestinal  obstruction.  Several  points  help  to  locate  the  trouble 
even  when  no  marked  tumor  is  present.  The  presence  of  pain  over 
the  region  of  the  obturator  foramen  directs  the  attention  to  that 
point,  and  pressure  made  there  projects  a  pain  down  the  inner  side 


Fig.  472. — Umbilical  hernia:  repair  of  abdominal  wall.     (Mayo.) 


of  the  thigh  to  the  knee,  along  the  course  of  the  obturator  nerve.     In 
the  female,  vaginal  examination  will  reveal  the  tumor. 

In  this  form  of  strangulated  hernia,  taxis  is  useless  and  likely  to  be 
very  harmful,  and  therefore  must  never  be  employed.  A  herniotomy 
must_be  done  without  delay,  though  in  these  cases  it  is  a  procedure 


630 


STRANGULATED   HERNIA 


by  no  means  simple.  Several  anatomical  points  must  be  borne  in 
mind.  The  hernia  usually  comes  out  through  the  upper  part  of  che 
obturator  membrane  and  is  covered  over  by  the  pectineus  muscle. 
It  may  work  into  the  pectineus  or  it  may  lie  on  a  lower  level,  working 
into  the  obturator  externus.  The  pectineus  is  usually  the  chief 
suide  to  the  hernia. 


m-. 


Fig.    473. — Obturator    hernia. 


A,  Hernial  sac-obturator    artery;    B,    pectineus;    C,  ad- 
ductor longus.     (Lejars.) 


The  obturator  vessels  and  nerve  are  usually  found  behind  and  to 
the  outer  side  of  the  neck  of  the  hernia.  The  femoral  vessels  lie 
to  the  outer  side.  It  is  the  obturator  membrane  which  constitutes 
the  constricting  ring. 

The  operation,  chiefly  as  described  by  Treves,  is  as  follows:  The 
pelvis  is  elevated,  the  thigh  flexed  and  adducted,  the  femoral  artery 
located,  and  about  a  finger's  breadth  internal,  an  incision  is  made  from 


SIRANGULAIED    UMBILICAL   HERNIA  6^1 

the  spine  of  the  pubes  downward  for  3  or  4  inches.  Incise  the 
skin,  the  subcutaneous  fat  and  the  fascia  lata,  and  expose  the  adduc- 
tor longus.  Catch  up  the  deep  external  pudic  artery.  Retract  the 
adductor  brevis  and  beneath  this  is  the  pectineus  whose  fibers  are 
separated  by  blunt  dissection;  or,  if  necessary,  divided  in  order  to 
expose  the  sac  (Fig.  473). 

When  the  sac  is  once  in  view,  free  it  completely  up  to  the  neck. 
The  obturator  membrane  is  now  to  be  nicked,  observing  first  the 
course  of  the  arteries.  It  may  be  better,  however,  to  open  the  sac 
at  once,  cleanse  the  contents,  and  endeavor  to  insinuate  the  finger 
alongside  the  bowel  and  stretch  the  strangulating  fibers;  failing  in 
this,  to  divide  them,  keeping  in  mind  the  possibility  of  a  hemorrhage. 
If,  in  spite  of  precaution,  this  occurs,  tampon  firmly  against  the 
obturator  membrane,  and  when  the  tampons  are  removed  one  by  one, 
the  bleeding  points  may  be  recognized  and  clamped.  Finally  the 
intestine,  if  sound,  is  reduced,  the  sac  dissected  and  ligated  high  up, 
and  the  external  wound  sutured. 

Lejars  remarks  that  one  may  find  in  the  sac  of  a  strangulated 
obturator  hernia  not  only  bowel  and  omentum,  but  also  the  tubes 
and  ovaries,  the  bladder  and  the  appendix;  and  that  it  is  well  to 
be  forewarned  of  these  possibilities,  which  may  greatly  complicate 
an  operation  at  best  never  simple. 

Of  strangulation  of  other  forms  of  hernia — sciatic,  lumbar,  perineal, 
vaginal — it  need  only  be  said  that  they  are  too  rare  to  be  with  profit 
considered  here. 


CHAPTER  XII 


RADICAL  CURE  OF  INGUINAL  HERNIA 


^  PO  TEt P 


The  radical  cure  of  hernia  may  be  attempted  at  the  operation  for 
strangulated  hernia  under  the  conditions  defined.  But  aside  from 
those  emergency  cases  there  are  others  in  which  the  family  doctor 
wiU  feel  it  his  duty  to  recommend  and  to  do 
the  operation.  His  results  will  be  excellent  if 
he  wisely  chooses  cases  not  beyond  his  skill. 
As  Veau  says,  he  should  select  only  such  as 
are  small,  reducible,  congenital.  The  large 
hernias  are  difficult  to  handle  and  recurrence 
will  be  almost  certain.  The  irreducible  hernias 
may  have  acquired  adhesions  that  can  scarcely 
be  broken  up  without  severe  injury  to  the  gut. 
With  respect  to  age,  the  ideal  case  is  a  young 
man  fifteen  to  twenty-five  years  old,  who  has 
well-developed  abdominal  walls,  a  well-defined 
external  abdominal  ring,  and  a  hernia  easily  con- 
trolled by  a  truss. 

Under  these  favorable  conditions,  the  hernia 
rarely  recurs;  but  almost  certainly  it  will  recur 
if  suppuration  foUows  the  operation,  and  there- 
fore absolute  asepsis  is  the  sine  qua  nan  of 
success. 

Surgical  Anatomy. — The  hernia,  then,  which 
the  general  practitioner  should  undertake  to 
operate  on  is  an  external  or  oblique,  which 
escapes  from  the  abdominal  cavity  through  the 
internal  ring  to  the  outside  of  the  deep  epigastric  artery  and  follows 
the  inguinal  canal  down  to  the  external  ring  (Fig.  474). 

Beneath  the  skin  wiU  be  found  only  a  few  insignificant  vessels. 

632 


Fig.  474. — Transverse 
vertical  section  of  the 
inguinal  canal  showing 
relation  of  the  hernial 
sac.  GO,  external  ob- 
lique; PO,  internal  ob- 
lique; T,  transversalis; 
Ft,  transversalis  fascia; 
P,  peritoneum;  TC,  con- 
joined tendon;  Crem., 
cremaster;  cd,  vas  det- 
erens  in  contact  with 
the  hernial  sac  repre- 
sented in  black.    {Veau.) 


SURGICAL   ANATOMY 


633 


The  aponeurosis  of  the  external  oblique  is  easily  distinguished, 
strong  and  resistant,  and  its  fibers  bounding  the  external  ring  are 
thickened  to  form  the  "pillars"  of  the  ring.  Behind  it  lies  the  cord, 
which  includes  the  vas  deferens  and  its  accompanying  vessels  and 
nerves,  all  surrounded  by  a  common  sheath  derived  from  the  trans- 
versalis  fascia,  and  in  this  case,  it  contains  also  the  hernial  sac.  To 
reach  the  sac,  the  sheath  must  be  divided  and  the  elements  of  the 
cord  separated  from  the  sac. 


f<^-i 


Fig.  475. — The  primary  incision  for  hernia.      (Veau.) 

In  the  case  of  congenital  inguinal  hernia,  the  sac  is  very  thin  and, 
in  spite  of  precautions,  it  is  sometimes  torn  or  one  even  fails  to  find 
it.  The  chief  difficulty  of  the  operation  centers  around  the  recogni- 
tion and  dissection  of  the  sac.  The  posterior  wall  of  the  inguinal 
canal  is  formed  by  the  conjoined  tendon,  the  transversalis  fascia,  and 
the  peritoneum. 

The  purpose  of  the  operation  is  to  reconstruct  the  posterior  wall 
and  restore  the  obHquity  of  the  canal,  and  the  "Bassini"  operation 
is  the  type  the  inexperienced  operator  can  best  imitate. 

Operation. — Prepare  the  field  most  scrupulously — abdomen, 
thigh,  and  scrotum.  Employ  general  anesthesia,  as  a  rule,  al- 
though local  and  spinal  anesthesia  are  available. 


634 


RADICAL   CURE    OF   INGUINAL   HERNIA 


Begin  b>'  locating  the  external  ring,  which  is  to  be  the  first  point 
of  attack. 

The  incision  will  extend  from  this  orifice  to  a  point  just  over  the 
internal  ring,  which  lies  3-^  inch  above  the  middle  of  Poupart's 
ligament.  The  incision,  then,  beginning  above  (on  the  right),  ex- 
tends downward  and  forward  to  the  spine  of  the  pubes,  where  it 
bends  a  little  to  become  more  vertical  and  ends  in  the  base  of  the 


Fig.  476. — The  external  oblique  exposed  and  the  external  ring  developed.     {Veau.) 

scrotum  (Fig.  475).  However  large  the  hernia  may  be,  one  need  not 
extend  the  incision  further,  so  lax  and  distensible  are  the  scrotal 
tissues. 

Having  divided  the  skin  and  subcutaneous  tissues,  catch  up  and 
ligate  the  small  vessels.  Next  divide  the  fatty  tissues  layer  by 
layer  down  to  the  aponeurosis  of  the  external  oblique,  which  lies 
deeper  than  one  may  expect. 

Now,  with  the  grooved  director,  completely  expose  the  pillars  of 
the  ring.  Do  not  neglect  this  as  it  is  a  most  important  step  in  the 
operation.  The  inner  pillar  is  easily  found,  but  the  outer  pillar  is 
covered  by  the  cord  and  a  little  patience  is  required  to  get  it  well 
exposed.     Catch  up  each  pillar  with  forceps;  these  are  not  to  be 


DISSECTING   THE   SAC  6.35 

loosened  until,  at  the  end  of  the  operation,  they  have  served  as  a 
guide  in  the  repair  of  the  external  ring  (Fig.  476). 

Now  comes  the  next  step  in  the  operation.  Carefully  divide  the 
aponeurosis  in  the  line  of  the  pillars  and  to  the  full  extent  of  the  skin 
wound.  Unless  one  cuts  deeply,  there  is  nothing  to  fear.  You  have 
now  laid  open  the  inguinal  canal  and  have  left  to  do  the  most  diffi- 
cult part  of  the  operation. 


Fig.  477. — The  external  oblique  divided,  exposing  the  cord  and  hernial  sac.     (Veau.) 

To  Find  and  to  Dissect  Out  the  Sac. — The  cord  is  covered  by  the 
cremaster  which  also  covers  the  hernial  sac.  You  may  begin  the 
search  for  the  hernial  sac  without  disturbing  the  position  of  the  cord, 
but  it  is  better  to  raise  it  up  out  of  its  bed.  To  do  this  follow  along 
the  external  pillar  and  Poupart's  ligament  and  you  will  find  it  easily 
disengaged  by  blunt  dissection  (Fig.  477).  Slip  the  left  index  finger 
under  and  support  the  cord.  The  sac  is  enclosed  in  the  fibrous 
sheath  of  the  cord. 

Very  gently  incise  this  sheath,  using  a  sharp  bistoury  (Fig.  478), 
and  the  structures  of  the  cord  appear.  Rolling  them  between  the 
finger  and  thumb,  you  can  recognize  the  vas  deferens  by  its  form  and 
consistency.  You  can  see  the  distended  veins.  You  will  see  a 
whitish  transparent  membrane.  Catch  up  a  fold  of  it  with  the  for- 
ceps and  divide  its  base,  and  if  it  is  the  sac,  you  will  open  into  a  serous 
cavity  (Fig.  479).  Enlarge  the  orifice  sufficiently  to  introduce  a 
finger  and,  with  that  as  a  guide,  dissect  the  sac  from  its  associated 


636 


RADICAL   CURE    OF   INGUINAL   HERNIA 


Fig    478. — Dividing  the  fibrous  coverings  of  the  sac.     (Veau.) 


■J  iU!:t. 


::tit3 


Fig.  479. — Incising  the  hernial  sac.     (Veau.) 


DISSECTING    THE    SAC 


637 


structures  (Fig.  480).  It  is  often  a  difficult  task,  for  the  veins  and 
vas  deferens  are  glued  to  the  sac,  especially  in  the  congenital  hernia. 
Sometimes  pressing  and  stripping  the  tissues  back  with  a  gauze 
compress  facilitates  the  maneuver.  Still  there  need  be  no  great 
difficulty  if  only  all  the  coverings  are  divided  with  the  scalpel  or 
scissors,  exposing  a  plane  of  cleavage.  Pulling  and  tearing  and 
lacerating  the  tissues  in  the  effort  to  liberate  the  sac,  provokes 
a  capillary  oozing  and  predisposes  to  infection. 


Fig.  480. — The  index  finger  introduced  into  the  sac  which  is  being  separated  from  the  other 

structures  of  the  cord.     {Guibe.) 

It  is  important  that  the  sac  be  isolated  quite  to  the  internal  ring 
(Fig.  481) ;  otherwise  when  the  ligature  is  applied  there  will  be  formed 
a  peritoneal  diverticulum,  the  starting-point  later  of  another  hernia. 
Do  not  carry  the  dissection  further  than  the  internal  ring  for  fear  of 
wounding  the  bladder. 

Assure  yourself  now  that  the  sac  is  empty  by  passing  a  finger  up 
into  the  abdominal  cavity.     Now  transfix  the  neck  of  the  sac  with  a 


63S 


RADICAL   CURE    OF   INGUINAL   HERNIA 


Fig.  481. — The  sac  separated  from  the  cord;  the  cord  in  the  bottom  of  the  wound;  on 
either  side  are  the  lips  of  the  external  oblique,  the  forceps  still  attached  to  the  pillars  of  the 
external  ring.     (Veau.) 


Fig.  482. — Ligation  of  the  neck  of  the  sac.     {Veau.) 


ABDOMINAL   REPAIR 


639 


needle  carrying  a  catgut  ligature  (Fig.  482)  and  tie  in  the  manner  in- 
dicated in  figure  (Fig.  483).  If  the  ligature  merely  encircles  the 
neck,  it  is  too  likely  to  slip  off.  Do  not  cut  off  the  ends  of  the  liga- 
ture until  through  dealing  with  the  sack.  Amputate  the  sac  within 
3^^  inch  of  the  ligature  and,  if  everything  is  all  right,  cut  the 
threads  and  the  stump  disappears  in  the  cavity.  Sellenings  proposes 
to  dispense  with  the  dissection  of  the  sac.  After  it  is  exposed,  in- 
cised, and  emptied,  he  obliterates  it  by  passing  a  purse  string  around 
its  neck  at  the  internal  ring  and  suturing  the  rest  of  its  length  (Amer. 
Jour.  Surgery,  March,  1909). 


Fig.  483. — Illustrating    method    of    ligating 
the  sac.     (Veau.) 


Fig.  484. — The  cord  drawn  to  one  side 
while  the  posterior  wall  of  the  canal  is 
restored  by  suture  of  the  conjoined  tendon 
to  the  shelving  edge  of  Poupart's  ligament. 
(Veau.) 


Suture  of  the  Abdominal  Walls. — This  is  the  next  step.  Draw  the 
cord  down  out  of  the  way  for  the  moment  and  expose  the  shelving 
inner  edge  of  Poupart's  ligament,  which  is  to  be  sutured  to  the  free 
border  of  the  conjoined  tendon.  In  other  words,  the  internal  oblique 
and  transversalis  are  to  be  sutured  jointly  to  Poupart's  ligament. 

Through  this  shelving  edge  near  the  pubis  pass  a  chromic  catgut 
suture  on  a  curved  needle  and  carry  it  through  the  corresponding 
part  of  the  conjoined  tendon  (Fig.  484),  and  apply  three  or  four  such 
sutures  (Fig.  485).     In  this  manner  reconstruct  the  posterior  wall  of 


640 


RADICAL   CURE    OF   INGUINAL   HERNIA 


Complete   the  hemostasis. 


the  inguinal  canal.     Place  the  cord  back  in  position  upon  this  line  of 
sutures. 

Now  draw  the  edges  of  the  divided  aponeurosis  into  position  by 
means  of  the  forceps  attached  to  the  pillars  at  the  beginning  of  the 
operation.  Begin  the  repair  by  a  chromic  catgut  suture  at  the  upper 
end  of  the  wound  (Fig.  486)  and  pass  six  or  eight  in  this  manner. 
The  last  will  rejoin  the  pillars  and  restore  the  external  ring,  and 
when  these  are  all  tied  the  anterior  wall  of  the  canal  is  thus  recon- 
structed. There  is  some  danger  of  making  the  external  ring  too 
small  for  the  cord  (Fig.  487),  with  the  result  finally  that  the  testicle 
atrophies. 

A  scrotal  hematoma  may  develop 
unless  one  is  very  particular  about 
the  oozing. 

Complete  the  operation  by  suture 
of  the  skin  wound  with  silk-worm- 
gut,  leaving  in  it  a  small  drainage- 
tube  if  you  fear  infection  or  oozing; 
otherwise  this  is  not  necessary;  still 
it  does  no  harm. 

The   dressing    is   of    extreme   im- 
portance.    Cover  the  wound  with  a 
strip  of  moist  gauze,  fix  it  with  collo- 
dion, and  then  apply  the  ordinary 
A  double  spica  bandage  will  greatly 
If  drainage  was  employed,  remove 
Otherwise  do 
If  the  tem- 


FlG. 


485. — Posterior  wail-repair  com- 
plete.     (Veau.) 


gauze  and  cotton  dressing. 

diminish  the  chance  of  infection. 

the  tube  in  two  or  three  days  under  strictest  asepsis. 

not  disturb  the  dressing,  but  watch  the  temperature. 

perature  runs  up  to  101°  on  the  third  day,  open  up  the  wound  by 

removing  one  or  two  sutures,  and  if  there  is  any  pus,  drain. 

Delay  in  this  is  likely  to  result  in  extensive  suppuration,  and  a 
recurrence  of  the  hernia  is  thus  assured.  If  everything  goes  well, 
remove  the  stitches  on  the  eighth  day,  but  keep  the  patient  in  bed 
for  three  weeks.     A  truss  is  not  necessary. 

Rilus  Eastman,  of  Indianapolis,  recommends  a  modification  of  the 
final  suturing  especially  applicable  in  the  case  of  children.  His 
method  aims  at  the  closure  of  all  the  layers  by  a  single  tier  of  easily 


ABDOMINAL   REPAIR 


641 


removable  non-l)uried  sutures.  The  method  descril^ed  (Annals  of 
Surgery,  Jan.,  1906)  consists  in  the  reduction  of  the  sac  by  the  ordi- 
nary procedure.  A  Pagenstecher  celloidin  linen  suture  bearing  a 
needle  on  each  end  is  then  first  passed  through  Poupart's  ligament 


X^iSSSSSJ?^^* 


Fig.  486. — Reconstructing  the  anterior  wall  by  repair  of  the  external  oblique.     Forceps 
still  attached  indicate  the  position  of  the  ring.      (Veau.) 

from  without  inward  i  inch  from  its  free  margin.  It  is  next 
passed  through  the  outer  border  of  the  obliquus  externus  and  trans- 
versalis  muscles  and  brought  back  through  Poupart's  ligament 
about  1/3  inch  nearer  the  margin  than  at  its  first  point  of  passage. 


Fig.  487. — External  oblique  repaired.     {Veau.) 


The  needle  now  external  to,  and  above  Poupart's  ligament  is  made  to 
overlap  the  free  margin  of  the  ligament  and  the  aponeurosis  of  the 
external  oblique  by  carrying  the  thread  through  in  the  form  of  a 
simple  running  mattress  suture. 
41 


642  RADICAL   CURE    OF   INGUINAL  HERNIA 

The  needle  is  next  passed  through  the  superficial  fascia,  panniculus 
adiposus,  and  skin,  emerging  about  1/8  inch  from  the  skin  wound 
margin  upon  the  side  opposite  Poupart's  ligament.  When  traction 
is  made  upon  the  two  ends  of  the  suture  no  kinks  or  curls  remain, 
and  the  suture  is  tied  up  as  a  simple  loop.  Five  or  six  such  sutures 
are  required  to  coapt  the  wound  from  the  internal  ring  to  the  pubes. 
When  union  is  complete  they  are  easily  clipped  and  removed. 


CHAPTER  XIII 
RADICAL  CURE  OF  FEMORAL  HERNIA 

Aside  from  the  cases  of  strangulated  hernia,  the  general  practi- 
tioner should  not  undertake  the  operation  for  the  radical  cure  of 
femoral  hernia  without  due  consideration  and  without  warning  the 
patient  that  relapse  is  possible  and  even  frequent.  The  operation 
is  not  more  difficult  than  that  for  inguinal  hernia,  but  a  cure  is  much 
less  certain.  As  with  inguinal  hernia,  he  should  select  only  such 
cases  as  are  small  and  reducible. 

Surgical  Anatomy. — -The  sac  of  a  femoral  hernia  is  generally  thick 
and  imbedded  in  adipose  tissue  originating  in  the  extra-peritoneal 
layer.     (See  Strangulated  Femoral  Hernia.) 

The  relations  at  the  neck  are  of  the  greatest  importance.  To  the 
outside  is  the  femoral  vein  in  direct  contact,  easily  perforated  by  a 
careless  needle  and  producing  a  hemorrhage  that  can  be  arrested 
only  by  ligature  of  the  vein.  To  the  inside  is  Gimbernat's  ligament, 
sharp-edged  and  tense,  the  chief  structure  to  be  dealt  with  in  strangu- 
lation. Above  is  Poupart's  ligament,  separating  the  femoral  from 
the  inguinal  canal,  and  below  is  the  ramus  of  the  pubes,  thinly  cov- 
ered by  the  pectineus  and  its  fascia.  These  boundaries  are  unaccom- 
modating structures  in  the  matter  of  repair,  and  for  this  reason 
relapse  is  frequent. 

Operation. — The  anesthesia  and  preparation  are  the  same  as  for 
inguinal  hernia. 

The  incision,  parallel  with,  and  a  finger's  breadth  below  Poupart's 
ligament,  begins  (on  the  left  side)  at  the  spine  of  the  pubis  and  is 
usually  about  four  inches  in  length  (Fig.  488). 

Incise  in  the  same  manner  the  fatty  tissues,  layer  by  layer,  until 
the  easily  distinguishable  coverings  of  the  hernia  are  reached.  The 
line  of  cleavage  between  them  and  the  fatty  tissues  is  followed  and 
the  neck,  lying  high  and  deep,  is  exposed.     Poupart's  ligament  is 

643 


644 


RADICAL   CURE    OF   FEMORAL   HERNIA 


next  freely  exposed.  Where  coverings  seem  thinnest,  catch  up  a 
fold  with  the  dissecting  forceps  and  incise  the  base.  It  may  be  that 
the  incision  will  only  open  into  another  fatty  layer.  Divide  the  next 
layer  in  the  same  manner,  and  so  proceed  until  you  have  opened 
the  sac;  secure  its  edges  with  forceps  and  pass  an  index  finger  into 
the  cavity.  If  omentum  is  found  it  must  be  resected  (Fig.  489). 
Be  sure  there  is  no  adherent  bowel. 


Fig.  488. — Incision  for  femoral  hernia,      {^'eau.) 


Now  dissect  the  sac,  proceeding  slowly  and  methodically  until  the 
femoral  ring  is  reached.  Introduce  a  finger  to  be  sure  the  bowel  is 
protected,  and  transfix  and  ligate  the  neck  of  the  sac  as  in  inguinal 
hernia.     Again  recall  the  relations  of  the  femoral  ring  (Fig.  490). 

Obliteration  of  the  Femoral  Ring. — Retract  the  upper  angle  of  the 
wound  so  that  you  can  see,  divide  Gimbernat's  ligament  freely, 
cutting  horizontally  and  toward  the  pubes  (Fig.  491).  Poupart's 
ligament  can  now  be  approximated  to  the  pectineus.  Protect  the 
femoral  vein  with  a  retractor  and  pass  the  first  suture  adjoining  it, 
using  a  strong  curved  needle  and  No.  2  or  No.  3  catgut. 

The  needle  enters  the  pectineal  fascia,  grazes  the  bone,  comes  out 
a  little  higher,  and  then  passes  up  to  the  posterior  surface  of  the  liga- 


ABDOMINAL   REPAIR 


645 


mcnt  and  forward  through  it  (Fig.  492).  Place  four  sutures  in  this 
manner  before  tying  (P'ig.  493).  Tie  them  successively  from  without 
inward.  It  is  this  line  of  suture  alone  that  will  be  efficient,  but  suture 
the  fascia  if  you  wish,  and  finally  the  skin. 

The  subsequent  treatment  is  the  same  as  in  inguinal  hernia. 

Such  is  the  method  which  Veau  recommends,  and  which  has  the 
great  merit  that  it  is  anatomical.  But  there  are  many  differences 
of  opinion  as  to  the  best  method  of  closing  the  femoral  ring,  and  as 
to  the  advisability  of  even  closing  it  at  all. 


Fig.  489. — Resection  of  the  omentum.     (Guibe.) 


Ochsner  enunciates  the  principle,  applying  it  to  the  radical  cure 
of  femoral  hernia,  that  circular  openings  in  any  part  of  the  body, 
will  certainly  close  unless  kept  open  by  a  mucous  or  serous  lining. 
Wherever,  therefore,  the  femoral  ring  is  well  defined,  he  is  content 
with  high  ligation  of  the  sac  and  dissection  of  all  the  fat  and  simple 
closure  of  the  wound.  With  a  technic  thus  reduced  to  the  simplest 
terms,  he  obtains  excellent  results.  Unfortunately,  the  femoral 
ring  cannot  always  be  defined  as  a  circular  opening,  and  especially 
after  the  operation  for  strangulated  hernia. 

Coley  in  the  main  agrees  with  Ochsner,  but  lays  somewhat  more 
stress  on  the  closure  of  the  femoral  canal. 


646 


RADICAL   CURE    OF   FEMORAL   HERNIA 


The  cure  is  the  more  perfect  and  certain,  we  think,  if  a  more  partic- 
ular care  is  given  to  the  closure  of  the  femoral  ring,  to  obliteration  of 
the  femoral  canal.  Especially  in  case  the  hernia  is  of  long  standing, 
the  opening  large,  the  structures  stretched  and  weakened. 


Fig.  490. — The  neck  of  the  sac  ligated  and     Fig.  491. — Femoral     hernia;     incision     of 
cut  off.      Above,  Poupart's  ligament;  below,  Gimbernat's  ligament.      {Veau.) 

the  ramus  of  the  pubes;  internally,    Gimber- 
nat's ligament.      (Veau.) 


Fig.  492. — Suturing  Poupart's  ligament 
to  pectineal  fascia.     {Veau) 


Fig.  493. — Suture    of    Poupart's    ligament 
and  pectineal  fascia  completed.     iVeau.) 


Proceed  as  described  in  the  case  of  strangulated  hernia,  to  expose 
liberate,  and  ligate  the  sac,  dividing  Gimbernat's  Ugament  to  give  a 
good  exposure.    Ligate  the  sac  high. 

The  peritoneum  is  now  freed  from  contact  with  the  abdominal 
wall,  holding  it  back  out  of  the  way  with  a  flat  retractor.  The  vein 
which  is  freely  exposed  is  drawn  outward. 


ABDOMINAL   REPAIR 


647 


Poupart's  ligament  is  now  lifted  up  and  the  free  borders  of  the 
internal  oblique  and  the  transversalis  exposed  above,  and  Cooper's 
ligament  below.  It  is  these  structures  which  are  to  be  drawn  into 
contact.  The  first  suture  is  passed  close  to  the  femoral  vein.  It  is 
the  most  difhcult  because  the  structures  from  within  outward 
become  more  deeply  placed. 

The  remaining  two  or  three  sutures  appproach  the  pubes,  the  last 
reaching  up  behind  Gimbernat's  ligament  (Fig.  494).  Some  diffi- 
culty may  be  experienced  in  passing  these  sutures,  for  Cooper's 
ligament  is  quite  resistant. 


Fig.  494. — Radical  cure  of  femoral  hernia.  The  first  plane  of  sutures  approximates  the 
border  of  the  internal  oblique  and  transversalis  to  Cooper's  ligament — the  periosteum  of  the 
ilio-pectineal  line.     Gimbernat's  ligament  divided,  the  femoral  vein  drawn  outward.     (Guibe.) 


The  second  and  superficial  plane  of  sutures  approximates  Poupart's 
ligament  to  the  pectineal  fascia  (Fig.  498).  Thus  the  femoral  canal 
is  completely  obliterated  by  two  strong  fascial  planes.  The  super- 
ficial fascias  are  sutured  to  obliterate  any  dead  spaces  and^the  skin 
repaired. 

In  the  case  of  the  male  or  for  that  matter  in  the  difficult  cases  in  the 
female  the  inguinal  canal  may  be  opened  exactly  as  in  inguinal  hernia. 
The  cord  is  drawn  down,  the  transversalis  fascia  divided,  avoiding 
the  deep  epigastric  artery,  and  the  neck  of  the  sac  exposed.     It  is 


648 


RADICAL   CURE    OF   FEMORAL   HERNIA 


Fig.  495. — Radical  cure  of  femoral  hernia.  The  first  row  of  sutures  is  tied  and  the  second 
passed,  approximating  Poupart's  ligament  and  the  pectineal  fascia.  The  femoral  vein  drawn 
to  the  outer  side  must  be  avoided.      (Guibe.) 


Fig.  496. — Radical  cure  of  femoral  hernia  by  the  inguinal  route.  The  sac  is  dissected  out, 
opened,  emptied,  and  ligated.  The  cord  displaced  downward,  the  vein  outward.  The 
border  of  the  external  oblique  drawn  upward  exposing  the  internal  oblique  which  will 
be  sutured  to  Cooper's  ligament  after  the  sac  is  cut  off. 


ABDOMINAL   REPAIR  649 

freed  from  its  pouch  in  the  femoral  canal,  brought  out  of  the  wound, 
opened,  emptied  and  ligated  (Fig.  496). 

The  borders  of  the  internal  oblique  and  transversalis  are  approxi- 
mated to  Cooper's  ligament — in  other  words,  the  periosteum  of  the 
ilio  pectineal  line,  avoiding  the  femoral  vein  as  described  above. 
Poupart's  ligament  is  next  approximated  to  the  pectineal  fascia,  the 
cord  is  replaced'  and  the  incision  in  the  external  oblique  repaired  and 
the  operation  completed  as  for  inguinal  hernia. 


CHAPTER  XIV 
ENTERECTOMY.    INTESTINAL  ANASTOMOSIS 

Resection  of  a  segment  of  the  small  intestine  may  be  a  necessary 
part  of  several  emergency  operations.  It  may  be  required  following 
gunshot  or  other  lacerating  wounds  of  the  intestine;  it  may  be  neces- 
sary in  certain  wounds  of  the  mesentery  and  in  the  gangrene  of  stran- 
gulated hernia. 

Large  wounds  of  the  gut,  those  which  carry  away  more  than  one- 
half  the  circumference,  require  resection,  for  any  form  of  repair  is 
likely  to  result  in  stricture.  In  the  case  of  multiple  perforations,  it  is 
safer  to  resect  than  to  attempt  separate  repair  of  the  orifices.  A 
small  wound  of  the  omentum  near  the  intestinal  border  may  require 
an  extensive  resection,  for  an  inch  of  mesentery  at  that  level  may 
contain  the  blood  supply  of  2  feet  of  intestine. 

Resection  of  the  bowel  implies  anastomosis,  and  this  may  assume 
one  of  three  forms:  it  may  be  end-to-end — ^termino-terminal,  termino- 
lateral,  or  latero-lateral. 

The  end-to-end  anastomosis  is  preferable  following  resection. 
The  method  employed  may  be  either  by  suturing — -circular  enteror- 
rhaphy — or  by  the  Murphy  button  or  some  of  the  other  mechanical 
devices,  such  as  Robson's  bone  bobbin  or  Frank's  decalcified  bone 
coupler.  With  the  great  majority  of  surgeons,  suturing  is  the 
method  of  choice,  although  the  casual  operator  may  not  yet  be 
ready  to  discard  the  mechanical  device. 

Moynihan,  in  his  great  work  on  abdominal  operations,  sums  the 
matter  up  in  this  wise:  "The  use  of  mechanical  appliances  is  no 
longer  necessary;  these  have  played  their  part — a  most  important 
part,  I  gratefully  admit — in  the  development  of  surgical  work,  and 
it  is  now  time  that  their  surgical  use  should  be  abandoned.  They 
have  been  useful,  nay,  indispensable  steps  in  the  march  of  progress. 
To  Murphy  above  all  other  surgeons — for  his  instrument js^one  of 

6.^0 


TECHNIC   OF   RESECTION  65 1 

the  most  ingenious  mechanical  contrivances  ever  invented — -we 
should  gratefully  acknowledge  the  debt  we  owe.  The  weightiest 
argument  against  all  mechanical  aids  to  anastomosis  is  this — 'they 
are  unnecessary.  By  their  aid  we  do  not  accomplish  anything  which 
cannot  be  accomplished  with  equal  rapidity  and  greater  safety  by 
simple  suture.  We  have  nothing  to  gain  from  their  use  and  we  risk 
much  by  leaving  something  behind  which  may  be  and  has  been  the 
direct  cause  of  danger  and  of  death.  The  day  of  mechanical  aids  is 
over.  The  buttons  and  the  bobbins,  the  elastic  ligatures  and  the 
forceps  of  many  forms  have  no  more  than  a  historical  interest." 

Technic  of  Resection. — The  first  essential  of  this  procedure  is 
that  all  the  impaired  gut  be  removed.  Otherwise  subsequent  slough 
and  perforation  are  almost  a  certainty.  There  is  a  limit,  of  course, 
to  the  length  of  the  segment  which  may  be  safely  removed,  but  in  the 
ordinary  operation  one  need  not  fear  to  remove  too  much.  Cases  are 
on  record  in  which  as  much  as  lo  feet  of  the  small  intestine  have 
been  removed  with  recovery.  As  Moynihan  said,  it  is  not  so  much 
a  question  of  how  much  is  removed  as  how  much  is  left  to  carry  on 
the  intestinal  functions. 

A  second  requisite  in  resection  is  that  the  blood  supply  of  the  bowel 
be  left  unimpaired.  Lack  of  precaution  in  this  respect  may  nullify 
an  otherwise  careful  operation. 

The  integrity  of  a  given  part  of  bowel  is  absolutely  dependent 
upon  the  condition  of  the  vessels  which  arise  from  the  last  arterial 
arch  to  supply  it.  It  must  be  remembered  that  the  vasa  intestini 
tenuis  break  up  into  a  number  of  freely  anastomosing  arches,  but 
the  terminal  branches  anastomose  but  little.  It  is  this  charac- 
ter of  the  circulation  which  determines  the  mode  of  section  of  the 
mesentery. 

The  third  principle  constantly  to  be  borne  in  mind  is  that  the  perito- 
neum is  to  be  completely  protected  from  contamination  by  the 
bowel  contents.  It  is  true  of  all  the  hollow  viscera  that  their  con- 
tents are  more  or  less  septic,  always  sufficiently  so  to  produce  perito- 
nitis. The  bowel,  then,  must  always  be  temporarily  constricted 
beyond  the  limits  of  the  section.  This  is  ordinarily  done  by  means 
of  intestinal  clamps  or  by  elastic  ligature  or  by  gauze  strips  passed 
through  a  button-hole  in  the  mesentery. 


652 


ENTERECTOMY.      INTESTINAL   ANASTOMOSIS 


Not  only  must  the  intestinal  contents  be  restrained,  but  also  the 
field  of  operation  must  be  shut  off  from  the  peritoneal  cavity  and 
from  contact  with  the  rest  of  the  viscera  by  means  of  sterile  com- 
presses. The  larger  and  more  deeply  placed  of  these  are  not  to  be 
removed  until  the  end  of  the  operation;  the  smaller  and  more  super- 
ficial should  be  changed  from  time  to  time  as  soiled. 


Fig.  497. — Resection  of  the  bowel;  showing  lines  of  incision  of  bowel  and  omentum. 

To  resect  a  portion  of  the  intestine,  then,  begin  by  getting  the 
injured  coil  well  into  view  and  pack  around  it  with  sterile  compresses. 
It  may  be  advisable  as  a  further  security  now  to  put  the  patient  in 
the  Trendelenburg  position.  Strip  the  portion  of  bowel  to  be  re- 
moved, so  as  to  empty  it,  and  apply  a  clamp  well  beyond  each  end 
of  the  condemned  segment.  The  clamps  are  not  placed  directly 
across  the  bowel,  but  obliquely,  so  that  more  of  the  convex  than  of 
the  mesenteric  border  is  included.  A  portion  of  the  mesentery  is 
included  in  the  bite  of  the  forceps. 

The  lines  of  the  section  are  prolonged  into  the  mesentery  so  thart 


TF.CIINIC   OF   RESECTION 


A53 


they  meet  just  short  of  the  nearest  arterial  arch.  It  is  better  to 
make  the  base  of  the  mesenteric  wedge  even  narrower  than  the 
mesenteric  margin  of  the  intestinal  segment.  There  is  then  scarcely 
any  danger  that  the  circulation  will  be  impaired  (Figs.  497,  498). 
If  a  lateral,  instead  of  an  end-to-end,  anastomosis  is  in- 
tended, the  technic  may  be  varied  with  great  advantage.  Under 
such     circumstances     proceed     in     this     manner:     Determine     the 


Fig.  498. — Resection  of  bowel;  showing  segment  of  bowel  and  omentum  removed. 


lines  of  section;  free  the  mesentery  opposite,  for  a  short  distance 
and  apply  a  clamp  to  the  bowel  but  not  including  the  mesentery; 
shift  the  clamp  so  as  to  flatten  a  segment  of  the  bowel  an  inch  long. 
Ligate  both  ends  of  this  segment  and  cut  between  the  sutures,  wrap- 
ping the  stump  of  the  healthy  portion  in  sterile  compresses.  Pass 
to  the  other  line  of  section  and  treat  it  in  the  same  manner.  The 
portion  of  bowel  to  be  removed  is  now  freed  of  its  mesentery,  dividing 
it  parallel  with,  and  an  inch  from,  the  gut,  catching  the  vessels  one 


654 


ENTERECTOMY.      INTESTINAL   ANASTOMOSIS 


by  one  as  divided.  To  each  of  the  remaining  stumps  a  purse-string 
suture  is  applied  for  the  purpose  of  burying  the  ligated  ends;  are 
further  closed  by  a  row  of  Lembert  sutures  (Fig.  499).  Following 
this  step,  the  lateral  anastomosis,  to  be  described  further  on,  can 
be  carried  out. 

Technic  of  End-to  -end  Anastomosis. —  (a)  By  suture.  Employ  two 
lines  of  suture.  One  perforates  the  bowel  wall,  brings  the  cut  edges 
into  accurate  contact,  and  is  hemostatic;  it  may  be  called  the  ''per- 
forating" suture.  The  other  passes  only  through  the  serous  and 
muscular  coats — -or  even  better  the  submucous — ^and  after  the  man- 
ner of  the  Lembert  suture  brings  the  serous  surfaces  into  contact, 
buries  the  perforating  sutures  and  effectually  prevents  any  of  the 


Fig.  499. — Resection  of  the  bowel  preparatory  to  lateral  anastomosis,  showing  manner  of 

treating  the  intestinal  stump. 


bowel  content  from  reaching  the  peritoneal  cavity.  Most  surgeons 
employ  a  straight  needle  and  silk.  Moynihan  likes  the  curved  needle 
and  celluloid  thread. 

To  introduce  the  suture  begin  by  placing  the  clamps  side  by  side, 
bringing  the  posterior  surfaces  of  the  bowel  into  contact.  Con- 
nect these  two  surfaces  by  a  continuous  sero-serous  suture,  extending 
from  the  mesenteric  border  to  the  convex  border  (Fig.  500).  Leave 
the  thread  long  where  tied  at  the  point  of  beginning  and  catch  it  with 
forceps.  On  reaching  point  "B"  leave  the  needle,  still  threaded, 
but  wrap  it  in  gauze  and  lay  it  aside  for  the  moment. 

Now  begin  the  perforating  suture  at  the  mesenteric  margin.  The 
two  leaves  of  the  mesentery  separate  here  to  encircle  the  bowels, 
leaving  a  part  of  the  surface  bare.  The  stitch  must  be  passed  so  as  to 
bring  the  mesentery  in  contact  with  this  bare  area. 


TECHNIC   OF   END-TO-END   ANASTOMOSIS 


655 


Proceed  in  this  manner:  Pass  the  needle  through  the  bowel  wall 
(beginning  with  the  right  side)  about  %  inch  from  the  cut  edge, 
entering  the  mucus,  emerging  from  the  serous  coat  just  where  the 
mesentery  reaches  the  bowel.  Carry  the  needle  over  and  across  to 
the  left  side,  pass  it  through  into  the  lumen,  reversing  the  first  punc- 
ture. Pass  it  next  from  within  out,  perforating  the  wall  near  the 
mesenteric  juncture,  and  finally  perforate  the  right  bowel  wall  again, 
passing  from  without  inward.  The  knot  is  tied  within  the  lumen 
of  the  gut  at  the  original  point  of  entrance.     The  edges  of  the  mes- 


FiG.  500. — End-to-end  anastomosis;  the  first  part  of  the  sero-serous  or  Lambert  suture 
applied.     Beginning  the  inclusive  suture.      (Binnie.) 

entery  being  thus  brought  together,  the  suture  is  carried  continuously 
around  the  whole  circumference  of  the  gut  (Fig.  501).  The  punc- 
tures are  Mo  to  3^2  ii^ch  apart  and  the  work  is  facilitated  by  keeping 
the  thread  taut,  which  at  once  tightens  it  sufi&ciently  and  brings 
into  view  the  site  of  the  next  puncture.  The  end  of  the  suture  is 
knotted,  the  thread  left  long  at  the  beginning  and  thus  the  perfo- 
rating suture  is  completed.     Remove  the  clamps. 

It  remains  to  complete  the  sero-serous  suture  which  was  tempora- 
rily abandoned.  It  is  carried  from  the  convex  border  on  around  to 
the  mesenteric  border,  and  when  that  point  is  reached  the  perforating 
suture  is  completely  buried.  Knot  with  the  thread  left  long  in  the 
beginning  and  held  with  forceps,  and  thus  the  sero-serous  suture  is 


656 


ENTERECTOMY.      INTESTINAL   ANASTOMOSIS 


completed  (Fig.  502).  Finally  suture  the  rent  in  the  mesentery. 
This  must  never  be  neglected,  else  it  may  be  the  site  of  a  strangulated 
hernia.  The  line  of  suture  is  to  be  carefully  wiped,  the  compresses 
removed,  and  the  loop  returned  to  the  abdominal  cavity. 

(b)  By  the  Murphy  button  (Fig.  503).  The  bowel  is  resected  as 
described  above.  Begin  by  passing  a  purse-string  suture  around  the 
bowel  near  its  cut  edge,  involving  all  the  layers.     The  chief  concern 


Fig.  501. — End-toend  anastomosis;  the  first  part  of  the  Lembert  suture  buried  by  the  in- 
clusive suture  which  will  be  completed  before  resuming  the  Lembert  A  B.      {Binnie.) 


is  to  get  control  of  the  mesentery  where  its  layers  separate.  To  do 
this  pass  the  needle  through  one  layer,  on  into  the  lumen  of  the 
bowel;  out  again  through  the  bowel  wall  and  through  the  other  layer 
of  mesentery  (Fig.  504). 

When  the  suture  is  puckered  the  intermesenteric  space  is  obliter- 
ated. Now  grasp  one-half  of  the  button  with  forceps  and  introduce 
it  into  the  end  of  the  gut  so  that  when  the  purse-string  suture  is 
tightened  it  will  fall  into  the  groove  in  the  button. 


ANASTOMOSIS   BY    THF    MURPHY  BUTTON 


657 


Adjust  the  other  halt  of  the  Initton  in  the  same  manner.  The 
male  half  is  pressed  firmly  into  the  female  half,  noting  that  all  the 
edges  are  turned  in.  Strengthen  the  union  by  a  few  Lambert 
sutures.     Repair  the  rent  in  the  mesentery  and  the  anastomosis  is 


Fig.  502. — End-to-end    anastomosis    com- 
pleted.   A  and  B  to  be  knotted.     (Binnie.) 


Fig.   503  — Murphy  button. 


Fig.  505. — Anastomosis  with  Murphy  button  completed. 
{Binnie  after  DaCosla.) 


Fig.  504. — Purse- 
string  suture  (6)  run- 
ning over  edge'  of  bowel 
and  closing  space  be- 
tween mesentery  (c) 
at  (a).      {Stewart.) 


complete  (Fig.  505).     It  may  be  expected  that  the  button  will  pass 
about  the  tenth  day. 

Lateral  Anastomosis. — Proceed  as  before,  bringing  out  of  the  ab- 
dominal cavity  the  loops  to  be  anastomosed  and  pack  with  sterile 

42 


658 


ENTERECTOMY.      INTESTINAL   ANASTOMOSIS 


compresses.  Each  loop  is  clamped  and  the  two  clamps  laid  side 
by  side  so  as  to  bring  about  5  inches  of  the  bowel  walls  in  contact 
(Fig.  507). 

The  first  line  of  suture  is  to  be  applied  nearer  the  convex  than  the 
mesenteric  border  and  should  be  about  3  inches  in  length.  Unite 
the  opposed  surfaces  then  by  a  sero-serous  suture.     The  line  of 


I 


Fig.    507. — Lateral  anastomosis  facilitated     Fig.  508. — Lateral   anastomosis;   first   row 
by  use  of  clamps.    Continuous  suture  for  both  of  Lembert  sutures  applied.     (Binnie.) 

layers.     {Binnie.) 

suture  runs  toward  the  operator,  and  when  the  line  has  reached,  say 
3  inches,  the  needle  is  left,  still  threaded,  and  temporarily  laid  aside. 
The  next  step  consists  in  making  the  openings  which  are  to  afford 
the  means  of  communication  between  the  two  loops.  A  straight 
incision  about  3-^  inch  from  and  parallel  with  this  line  of  suture  lays 
open  the  bowel  down  to  the  mucosa.     Section  of  these  superficial 


d 


LATERAL   ANASTOMOSIS 


659 


coats  leave  exposed  an  ellipse  of  mucous  membrane,  and  this  ellipse 
should  be  trimmed  out  with  the  scissors.  The  other  loop  is  opened 
in  the  same  way. 


Fig.  509. — Lateral  anastomosis; 
first  part  of  the  through-and- 
through  suture  applied  (Binnie.) 


Fig.  Sio. — ^Lateral  anastomosis.  Applying 
last  of  the  Lembert  sutures.  Interrupted  in 
this  case,  use  the  continuous  instead.    (Binnie.) 


The  adjoining  edges  are  now  to  be  coapted  by  continuous  per- 
forating suture  (Fig.  508).     As  this  suture  progresses  the  opposite 


66o 


ENTERECTOMY.      INTESTINAL   ANASTOMOSIS 


angle  of  the  wound  is  reached,  but  without  interruption  it  continues 
to  draw  together  the  more  widely  separated  borders  (Fig.  509). 

When  it  has  reached  the  point  of  beginning,  the  terminal  thread 
is  knotted  with  the  first  which  was  left  long,  and  so  the  perforating 


Fig.   511. — Cross-section  of  lateral  anastomosis.      (Binnie.) 

suture  is  finished.     Remove  the  clamps,  wipe  the  bowxl,  and  now 
return  to  the  sero-serous  suture  and  continue  with  that  until  the  per- 


FiG.        512. — Termino-lateral      anastomosis. 
Clamps    and    continuous    suture    employed. 
(Binnie.) 


Fig.  513. — Termino-lateral 
anastomosis  completed. 
(Binnie.) 


forating  sutures  are  completely  buried  or,  in  other  words,  until  the 
sero-serous  suture  has  traveled  completely  around  the  bowel  and 
the  terminal  thread  knotted  with  the  primary  suture. 


TERMINO-LATERAL   ANASTOMOSIS  66 1 

If  preferred,  this  sero-serous  suture  may  be  an  interrupted  instead 
of  a  continuous  stitch  (Fig.  510),  but  the  continuous  suture  is  more 
rapidly  passed  and  is  in  every  respect  as  secure.  The  main  thing  to 
be  attained,  however,  is  that  the  serous  surfaces  be  brought  into 
contact  through  the  whole  circumference  of  the  bowel. 

Fig.  511  shows  the  appearance  of  the  bowel  on  cross  section  after 
such  an  anastomosis.  This  method  may  be  modified  in  many  ways, 
but  exemplifies  really  the  fundamental  principles  involved  in  any 
anastomosis  of  the  digestive  tube.  It  is  purposely  stated  in  its 
simplest  terms  and  shorn  of  detail. 

The  technic  of  the  termino-lateral  form  of  anastomosis  does  not 
differ  in  any  essential  detail  from  that  just  described  for  the  latero- 
lateral  form  (Figs.    512  and  513). 


CHAPTER  XV 
IMPERFORATE  ANUS 

A  correspondent  addresses  the  editor  of  the  Journal  of  the  Ameri- 
can Medical  Association  (September  8,  1906)  to  this  effect: 

"Mrs.  B.,  a  perfectly  healthy  woman  of  twenty-eight  years  of  age, 
after  a  normal  pregnancy,  gave  birth  to  a  fine  eight-pound  boy,  well 
nourished  and  healthy  looking,  and  perfect  in  every  way  except  there 
was  no  anus  nor  sign  of  any.  A  small  amount  of  meconium  was 
being  passed  through  the  urethra.  The  next  morning  a  local  surgeon 
was  called  in  counsel  and  an  incision  was  made  through  the  floor  of 
the  pelvis  and  dissected  up  along  the  coccyx,  but  no  rectum  was 
found  nor  trace  of  a  gut  until  the  sigmoid  flexure  was  reached  in  the 
free  peritoneal  cavity.  A  large  opening  in  the  sigmoid  was  followed 
by  a  discharge  of  feces.  No  attempt  was  made  to  stitch  the  gut  to 
the  wall  or  the  integument.  The  opening  was  not  closed  in  any  way 
and  no  dressing  applied,  except  that  the  nurse  was  directed  to  keep 
the  site  of  the  operation  sponged  with  a  saturated  solution  of  boracic 
acid  after  each  evacuation  of  the  bowels.  The  child  nursed  well  after 
the  operation  and  has  continued  to  do  so.  It  sleeps  nearly  all  the 
time,  but  has  had  no  elevation  of  temperature;  the  passages  come 
free  and  the  urine  is  passed  normally.  Can  you  suggest  any  means 
of  treatment  that  will  permit  the  child  to  grow  up  with  at  least  a 
slight  control  of  bowel  movement?" 

That  is  the  question  which  occurs  to  every  doctor  compelled  to 
deal  with  these  cases,  which  are  fortunately  rare.  The  little  being's 
life  rests  upon  the  doctor's  readiness  to  act;  and  if  it  survives,  whether 
or  not  it  carries  a  life-long  disability  depends  largely  upon  his  skill. 

It  usually  happens  in  the  course  of  such  cases  that  no  meconium 
passes  within  a  reasonable  time  after  the  baby's  birth.  It  grows 
restless,  perhaps  vomits,  and  for  the  first  time  it  is  suspected  that 
there  is  some  abnormality  about  the  rectum  or  anus,  which  an  exam- 

662 


OPERATIVE   TECHNIC 


663 


ination  verifies.  It  is  imperative  to  relieve  the  condition  at  once  and 
if  no  specialist  is  within  reach,  the  doctor  must  undertake  it.  He 
may  find  it  quite  easy  or  he  may  find  it  impossible. 

In  the  first  instance,  the  anus  and  rectum  may  be  both  fully  devel- 
oped, but  in  passing  a  finger  or  probe  into  the  orifice,  a  thin  bulging 
membrane  can  be  felt,  apparently  almost  ready  to  burst  when  the 
infant  cries.  A  sharp-pointed  bistoury,  wrapped  and  introduced 
along  the  finger  or  a  grooved  director,  easily  punctures  the  membrane 
followed  by  a  free  passage  of  meconium;  and  thereafter  the  bowel 


Fig.  514. — Incision  for  imperforate  anus.     (Veau.) 


readily  empties  itself.  The  mother  is  directed  to  dilate  the  opening 
daily  with  her  little  finger,  and  that,  with  an  occasional  stretching 
with  a  bougie,  is  sufficient. 

In  another  case  there  may  be  no  depression  where  the  anus  should 
be.  The  median  raphe  extends  unbroken  from  the  scrotum  to  the 
coccyx.  The  anus  is  absent  and  it  may  be  practically  impossible 
to  tell  how  high  up  in  the  pelvic  cavity  the  rectal  cul-de-sac  may  be; 
and  yet  it  is  one's  duty  to  hunt  for  it  through  the  perineum. 

Operation. — Put  the  patient  on  its  back  with  thighs  flexed  and 
pelvis  elevated — in  short,  in  the  lithotomy  position.  Employ  a  light 
chloroform  anesthesia,  not  that  there  is  any  danger  if  the  anesthesia 
is  carefully  conducted,  unless,  indeed,  the  operation  has  been  too  long 


664 


IMPERFORATE   ANUS 


delayed,  but  that  a  little  straining  on  the  patient's  part  may  help  to 
locate  the  bowel. 

Make  a  median  incision  from  the  base  of  the  scrotum  or  from  near 
the  posterior  vaginal  wall  to  the  coccyx,  which  must  be  exposed 
(Fig.  514).     A  number  of  eventualities  may  present: 

(i)  One  may  find  immediately  beneath  the  skin  some  of  the  fibers 
of  the  external  sphincter,  a  favorable  indication.  Split  these  fibers 
by  blunt  dissection.  Free  incision  may  spoil  their  usefulness.  Be- 
neath the  muscular  layer  appears  the  lobulated  fatty  tissue  peculiar 
to  the  new-born,  which  is  to  be  next  divided.     Here  one  must  go 


Fig.   515. — Retention  suture.     {Veau.) 

slowly,  keeping  in  the  middle  line  and  all  the  time  working  toward 
the  coccyx.  The  danger  is  in  front.  If  toward  the  hollow  of  the 
sacrum,  a  fluctuating  pouch  is  felt  or  a  brownish  rounded  tumor  is 
seen,  one  breathes  easy,  knowing  that  the  imperforate  gut  is  within 
reach.  But  do  not  be  in  a  hurry  to  open  the  gut.  It  is  first  to  be 
secured  by  passing  a  suture  on  each  side  of  the  middle  line  or  by 
catching  the  bowel  wall  with  forceps.  The  suture  should  not  per- 
forate the  bowel. 

Making  gentle  traction  on  the  bowel,  proceed  to  free  it  by  careful 
blunt  dissection.  Do  not  use  knife  or  scissors  to  divide  what  seem 
to  be  fibrous  bands,  for  it  is  possible  they  contain  the  blood  supply 
of  the  bowel;  and,  if  divided,  dangerous  bleeding  may  occur  or  the 
tissues  become  gangrenous. 


OPERATIVE   TECHNIC 


665 


As  the  pouch  is  freed,  it  is  gradually  pulled  down  iiUu  the  wound; 
and  if  they  were  not  passed  before,  two  sutures  are  now  passed  with 
which  eventually  to  fasten  the  gut  to  the  skin  opening  (Fig.  515). 
Now  is  the  time  to  open  the  pouch  and  let  the  meconium  flow  out. 
It  may  require  several  minutes  for  the  bowel  to  empty  itself.  Evert 
the  mucous  membrane,  enlarging  the  bowel  wound  a  little  if  neces- 
sary. Suture  the  mucous  membrane  directly  to  the  skin;  no  other 
tissues  should  intervene  (Fig.  516). 

Irrigate  thoroughly  and  apply  a  gauze  dressing,  which  is  changed 
as  often  as  soiled.     The  functional  result  is  often  surprisingly  good. 


Fig.  516. — Muco-cutaneous  suture.     {Veau.) 


Broncho-pneumonia  may  develop  when  the  operation  has  been  too 
long  delayed  and  septic  absorption  has  begun. 

(2)  The  pouch  cannot  be  drawn  down.  In  that  case  when  the  bowel 
is  opened  the  discharge  will  have  to  flow  over  the  raw  surfaces  of  the 
flesh  wound  which  will  need  to  be  kept  open  with  bougies.  Infec- 
tion is  a  constant  danger,  not  to  speak  of  lack  of  control  of  bowel 
movement. 

Better  than  to  leave  the  wound  in  this  condition,  the  coccyx  and  a 
part  of  the  sacrum  may  be  removed  and  the  gut  brought  out  poste- 
riorly. Still  better,  open  the  peritoneal  cavity,  find  and  draw  dow^n 
a  loop  of  the  sigmoid  to  fasten  in  the  wound. 

(3)  The  pouch  cannot  be  found.  Obtain  more  room  by  resecting 
the  coccyXj'^follow  the  sacrum  a  little  higher,  open  the  peritoneal 


666  IMPERFOEATE   ANUS 

cavity  and  search  for  the  cul-de-sac;  if  possible,  draw  it  down  into 
the  wound  and  suture. 

If  all  these  measures  fail,  there  is  nothing  to  do  but  make  an  arti- 
ficial anus  in  the  inguinal  region.  Indeed,  there  are  those  who  advise 
this  from  the  first  with  the  idea  that  later  the  operation  for  the  con- 
struction of  a  normal  anal  orifice  can  be  better  undertaken. 

Tuttle  says  (Diseases  of  the  Anus,  Rectum,  and  Pelvic  Colon)  that 
where  there  is  no  evidence  that  the  rectal  pouch  can  be  easily  reached, 
and  where  the  child  is  in  an  enfeebled  condition  w^ith  distended  ab- 
domen, fecal  vomiting,  and  nausea  in  progress,  one  should  not  hesi- 
tate to  choose  the  abdominal  route,  perform  an  inguinal  colotomy 
at  once  and  thus  afford  an  immediate  exit  to  the  intestinal  contents, 
and  an  escape  for  the  gases  which  are  causing  the  distention  and  the 
constitutional  disturbance. 

To  this  same  volume  the  reader  is  referred  for  a  full  discussion  of 
these  problems,  and  for  consideration  of  those  other  forms  of  imper- 
fect development  in  which  the  anus  has  abnormal  openings.  Such 
cases  are  not  strictly  emergencies,  for  usually  there  is  a  partial  means 
of  escape  for  the  bowel  contents. 


CHAPTER  XVI 

TORSION   OF  THE   PEDICLE   OF   OVARIAN   OR  UTERINE 
TUMORS ;  OF  THE  SPERMATIC  CORD ;  OF  THE  PEDI- 
CLE OF  THE  SPLEEN ;  OF  THE  OMENTUM 

Torsion  of  the  pedicle  of  an  ovarian  or  uterine  tumor  may  be  either 
chronic  or  acute;  in  the  one  case  developing  so  slowly  as  to  produce 
no  symptoms  or  even  no  effect  upon  the  tumor  unless  merely  to  in- 
hibit its  growth,  for  in  the  adhesions  are  new  sources  of  nutrition; 
in  the  second  case  developing  suddenly  and  producing  a  train  of 
symptoms  that  demand  immediate  relief.  The  acute  cases  alone, 
then,  are  to  be  regarded  as  emergencies. 

Cysts  of  the  ovary,  especially  those  which  are  spherical,  non-adher- 
ent, and  connected  by  a  long  pedicle,  are  most  liable  to  this  accident. 

Kelly  finds  two  causes  for  this  rotation.  The  first  of  these  is  in 
the  effort  of  a  large  cyst  to  accommodate  its  convex  surface  to  the 
concavity  of  the  distended  anterior  abdominal  wall.  The  second 
cause  is  found  in  contractions  of  the  anterior  abdominal  wall,  which 
act  upon  the  part  of  the  tumor  nearest  the  middle  line.  The  effect 
of  the  force  thus  applied  is  to  rotate  the  tumor.  In  the  case  of 
smaller  tumors  lying  in  the  pelvic  cavity  it  is  likely  that  unusual 
movement  in  the  intestine  or  readjustments  of  the  pelvic  viscera  may 
produce  the  same  effect.  Kelly  quotes  Kiistner  to  the  effect  that 
tumors  of  the  right  side,  as  a  rule,  rotate  from  left  to  right,  while 
left  ovarian  tumors  rotate  from  right  to  left. 

The  diagnosis  of  acute  torsion  is  not  difficult  if  an  ovarian  cyst  is 
known  to  be  present.  If  such  a  tumor  was  previously  unsuspected 
the  certain  diagnosis  may  be  impossible,  especially  if  the  case  is 
seen  late  and  general  peritonitis  is  developing. 

The  symptoms,  as  a  rule,  arise  without  warning.  There  are  severe 
colicky  pain,  vomiting,  marked  constipation,  and  the  appearances  of 
collapse.     Abdominal  rigidity  and  tension  rapidly  increase.     This  is 

667 


608    TORSION  OF  THE  PEDICLE  OF  OVARIAN  OR  UTERINE  TUMORS 

true  of  the  more  urgent  cases.  In  general,  the  severity  of  the  symp- 
toms vary  with  the  degree  of  torsion. 

Appendicitis  and  acute  intestinal  obstruction  present  the  greatest 
difficulties  in  differential  diagnosis  which  it  is  desirable  to  make,  not 
to  determine  the  advisability  of  operating,  but  to  determine  before- 
hand the  kind  of  operation  one  is  to  undertake.  Ranzi  (Berliner 
klin.  Wochenschrift,  Jan.  6,  1908)  reports  four  cases  of  torsion  of 
ovarian  cyst  which  were  not  differentiated  from  appendicitis,  except 
in  one  case,  before  the  operation,  and  in  this  case  by  the  pains  in 
urinating.  In  three  of  the  cases  there  had  evidently  been  mild 
attacks  of  torsion  which  had  subsided  and  which  had  been  diagnosed 
as  catarrhal  appendicitis. 

The  treatment  is  operative,  and,  as  has  been  indicated,  the  operation 
must  often  begin  as  an  exploratory  laparotomy,  for  though  the  symp- 
toms indicate  the  seriousness  of  the  case  they  may  not  reveal  its 
character.  Delay  is  dangerous  in  these  cases,  and  seldom  will  one 
regret  having  operated  early,  for  nearly  always  the  lesions  found 
exceed  the  expectation. 

The  appearances  once  the  abdomen  is  opened  will  depend  upon  the 
size  of  the  tumor,  the  degree  of  torsion,  and  the  time  of  intervention. 
Usually  the  tumor  will  be  found  enveloped  in  loops  of  intestine  bound 
together  by  soft  adhesions  (Fig.  517). 

These  adhesions  are  to  be  carefully  separated,  and  one  must  pro- 
ceed with  prudence  for  the  cyst  may  be  filled  with  pus  and  its  walls 
may  be  friable.  The  intestines,  detached,  are  to  be  held  out  of  the 
way  with  compresses  and  the  tumor  thus  brought  into  view.  Its 
nature  may  be  at  once  apparent  in  spite  of  the  fact  that  it  is  dis- 
colored, dark  red,  or  even  black.  If  it  is  a  cyst  not  quite  so  large, 
it  may  resemble  a  dilated  cecum.  Its  attachments  are  carefully 
broken  up,  and  gradually  working  toward  its  base  the  pedicle  is 
finally  defined. 

An  effort  is  now  made  to  lift  the  tumor  out  of  the  abdominal 
cavity,  and  there  need  be  no  hesitancy  in  enlarging  the  abdominal 
incision  if  necessary.  Usually  it  is  to  be  lifted  out  with  the  two  hands 
applied  to  its  base.  Occasionally  only  after  its  pedicle  is  untwisted 
is  it  possible  to  deliver  it. 

Next  the  pedicle  is  tied  near  its  point  of  implantation,  divided. 


i 


TORSION,    OVARIAN    CYST 


669 


and  thus  the  tumor  is  removed.     If  there  are  no  e\'idencx's  of  infec- 
tion the  abdomen  is  to  be  closed  without  drainage. 

Tumors  springing  from  the  uterus  are  much  less  likely  to  become 
twisted.     Yet,  in  the  case  of  large  non-pedunculated  fibroids,  the 


Fig.  517. — Torsion  of  the  pedicle  of  an  ovarian  cyst.      {Montgomery.) 


Uterus  itself  may  be  rotated  and  give  rise  to  symptoms  which  de- 
mand relief.  In  such  a  case  the  intervention  may  be  quite  complex. 
In  some  instances  a  myomectomy  may  be  sufficient.  The  uterine 
wall  is  incised  over  the  long  axis  of  the  tumor,  which  is  exposed  and 
peeled  out,  and  the  hemorrhage  checked  by  suture  of  the  uterine 


670    TORSION  OF  THE  PEDICLE  OF  OVARIAN  OR  UTERINE  TUMORS 

wound.  The  uterus  may  still  tend  to  rotate  and  may  require 
fixation. 

In  still  other  instances,  hysterectomy,  either  supra-vaginal  or 
complete,  may  be  the  procedure  necessary  for  relief.  This  will  be 
the  case  when  the  condition  of  the  uterine  wall  after  removal  of  the 
tumor  would  preclude  repair. 

Harsha  reports  to  the  Chicago  Medical  Society  (Annals  of  Surgery, 
Nov.,  1905)  a  case  of  torsion  of  the  pedicle  of  an  ovarian  cyst  in  a 
woman  of  thirty-three,  who  for  several  years  at  intervals  had  had 
attacks  of  intestinal  obstruction,  accompanied  by  pain  and  vomiting, 
lasting  for  three  or  four  days. 

Her  last  attack  began  suddenly  with  pain,  vomiting,  constipation, 
tenesmus,  accompanied  by  the  symptoms  of  shock.  At  the  end  of 
four  days  the  abdomen  was  opened.  A  cyst,  the  size  of  an  orange, 
with  twisted  pedicle  was  removed.  There  was  neither  peritonitis 
nor  gangrene.     There  had  been  no  further  indications  of  obstruction. 

In  a  second  case  the  cyst  was  as  large  as  a  fetal  head  and  black 
to  within  an  inch  of  its  implantation. 

Ochsner,  commenting  on  these  cases,  says  that  symptoms  of  ob- 
struction are  not  uncommon  in  such  cases  and  that  the  history  is 
often  that  of  volvulus. 

He  cites  a  case  in  which  the  abdomen  had  been  opened  by  a  prac- 
titioner who  believed  he  was  dealing  with  intestinal  obstruction. 
Having  opened  the  abdomen,  however,  he  discovered  a  large  black 
tumor.  Disconcerted,  he  stopped  his  operation,  hurriedly  trans- 
ported the  patient  to  the  Augustana  Hospital  where  Ochsner  com- 
pleted the  work. 

The  doctor  performing  an  emergency  laparotomy  must  not  have 
his  mind  too  definitely  fixed  on  one  diagnosis.  Expecting  one  thing, 
he  must  still  have  in  view  the  possibility  of  having  to  deal  wnth  one 
or  more  of  a  variety  of  conditions,  and  so  w^iU  not  be  taken  completely 
unaware. 

John  Cahill  and  Sir  William  Bennett  give  the  history  of  a  case 
which  well  exemplifies  the  difficulties  of  diagnosis,  the  occasional 
complexity  of  treatment,  and  the  dangers  of  delay  (London  Lancet, 
Dec.  8,  1906). 

The  patient,  aged  seventeen,  was  suddenly  seized  with  abdominal 


I 


TORSION   OF   THE   SPERMATIC   CORD  67 1 

pain.  There  was  some  tenderness  and  resistance  over  the  right  iliac 
fossa.  The  temperature  was  98.8°,  the  pulse  90.  Bowels  were 
emptied  by  enemata,  but  the  pain  continued.  On  the  third  day 
the  temperature  ran  up  to  101.8°  and  the  pulse  to  120. 

An  operation  was  still  refused  until  at  the  end  of  a  week  the 
patient's  condition  had  become  very  grave.  An  operation  for  appen- 
dicitis was  then  performed  and  the  appendix  found  adherent  and 
filled  with  pus,  in  addition  to  other  evidences  of  chronic  disease. 
Further  examination  revealed  a  dark,  firm  mass  occupying  the  upper 
part  of  pelvic  cavity  and  intimately  adherent  to  the  bladder  and 
uterus.  Exposed  by  extending  the  incision,  it  proved  to  be  an  ovar- 
ian cyst  the  size  of  a  cocoanut  with  a  thick  pedicle  twisted  upon 
itself  for  three-fourths  of  a  turn.  Its  walls  were  thin  and  blackish, 
and  its  contents  mainly  decomposed  blood.  The  cyst  was  removed 
and  the  patient  recovered. 

Dr.  Cahill,  commenting  on  the  case,  remarked  that  the  situation 
of  the  cyst  was  unusual  in  that  it  was  wedged  between  the  bladder 
and  uterus,  whereas  one  expects  to  find  such  a  tumor  in  Douglas' 
pouch. 

Sir  William  Bennett  says  that  although  cases  not  infrequently 
operated  upon  for  appendicitis  prove  to  be  cases  of  torsion,  yet  the 
coexistence  of  the  two  conditions  must  be  very  rare.  He  suggests 
that  in  this  case  the  appendicitis,  by  aggravating  the  intestinal 
peristalsis,  had  displaced  the  tumor  with  consequent  torsion  of  its 
pedicle. 

Angus  (British  Medical  Journal,  Jan.  27,  1906)  reports  an  attack 
in  a  child  of  six,  beginning  with  pain,  vomiting,  and  abdominal  dis- 
tention. By  the  rectum  a  mass  was  palpable  in  the  cul-de-sac.  A 
diagnosis  of  appendicitis  with  abscess  formation  was  made.  Opera- 
tion. The  appendix  was  inflamed  at  the  end  where  it  was  attached 
to  a  dark  cytic  swelling  in  Douglas'  pouch.  It  was  the  right 
ovary  darkly  congested,  large  as  a  duck's  egg,  and  with  twisted 
pedicle.     Its  contents  showed  it  to  be  an  ovarian  dermoid. 

TORSION  OF  THE  SPERMATIC  CORD 

Malformations  and  imperfect  descent  predispose  to  rotations  of 
the  testicle — an  accident  rare  yet  none  the  less  to  be  borne  in  mind 


672     TORSION  OF  THE  PEDICLE  OF  OVARIAN  OR  UTERINE  TUMORS 

as  a  possibility.  The  exciting  cause  is  usually  to  be  found  in  trauma. 
A  heavy  lift  or  strain  may  produce  it. 

It  is  readily  comprehended  that  an  incompletely  descended  tes- 
ticle shifting  backward  and  forth  through  the  external  ring  could  be 
forcibly  rotated.  The  rotation  may  occur  in  two  ways:  either  the 
testicle  with  its  tunica  vaginalis  may  be  turned  or  the  testicle  alone 
may  rotate.  The  spermatic  vessels,  nerve,  and  vas  deferens  are 
all  involved  in  the  resulting  torsion. 

The  symptoms  range  from  moderately  severe  to  grave.  Pain, 
nausea,  vomiting,  constipation,  and  tympanites  signalize  the  attack, 
and  soon  the  signs  of  local  inflammation  appear. 

In  the  more  serious  cases  the  pain  begins  abruptly  and  persists. 
It  usually  radiates  from  the  inguinal  region  and  lower  part  of  the 
abdomen,  and  may  be  intense  or  even  produce  shock.  The  con- 
stipation is  usually  relieved  by  enemata. 

The  presence  of  a  painful  tumor  in  the  inguinal  region  together 
with  the  symptoms  point  to  strangulated  hernia  and  torsion  of  the 
spermatic  cord  equally,  and  the  differential  diagnosis  may  be  a 
matter  of  difficulty.  The  pain  is  much  more  intense  and  sudden  in 
its  onset  than  epididymitis.  The  cord,  in  torsion,  can  be  felt  tender 
and  swollen;  it  cannot  be  felt  in  strangulated  hernia.  Of  course  in 
strangulated  hernia  the  constipation  is  absolute. 

Once  the  diagnosis  is  assured,  an  effort  to  untwist  the  cord  should 
be  made  and  occasionally  it  will  succeed.  It  is  recorded  of  patients, 
who,  having  had  several  attacks,  learn  to  give  themselves  relief.  If 
manipulation  fails  it  is  imperative  to  operate  without  delay,  for  there 
is  danger  of  gangrene  of  the  testicle. 

An  incision  extending  from  near  the  external  ring  follows  the  cord 
down  toward  the  base  of  the  scrotum.  Layer  by  layer  the  tissues 
are  divided  until  the  tunica  vaginalis  is  reached.  The  tissues  are 
often  edematous,  reddened,  and  swollen.  The  tunica  presents  itself 
as  a  thin-walled  sac.  Open  it  and  drain  away  the  serum  and  the 
testicle  will  be  found,  possibly  deformed,  perhaps  difficult  to  recog- 
nize, and  above  it  is  the  twisted  cord. 

Seize  the  testicle  and  rotate  it  from  right  to  left  in  order  to  relieve 
the  torsion  and  restore  the  circulation.  The  further  procedure  will 
depend  upon  the  integrity  of  the  testicle.     If  its  violet  color  fades. 


TORSION,   PEDICLE    OF   THE    SPLEEN  673 

if  the  congestion  diminishes,  it  is  almost  certain  the  testicle  will 
recover,  and  it  is  therefore  to  be  preserved.  If  it  is  black  or  mottled 
or  flaky,  remove  it  by  tying  the  cord  above  the  torsion  (see  Castra- 
tion). If  its  integrity  is  doubtful,  preserve  the  testicle  but  provide 
ample  drainage  for  the  tunica  vaginalis. 

Lichtenstern,  of  Vienna,  reports  a  case  of  torsion  of  the  spermatic 
cord  in  a  man  of  forty-six,  which  began  with  lifting  a  heavy  load. 
The  scrotum  soon  became  enlarged,  and  vomiting  and  constipation 
ensued.  A  diagnosis  of  inguinal  hernia  had  been  made,  and  efforts 
to  reduce  had  failed. 

At  the  time  of  entrance  at  the  hospital  his  temperature  had  reached 
102°  and  his  pulse  was  bad.  In  the  scrotum  was  a  large  tense  tumor 
and  in  the  inguinal  canal  another  smaller. 

On  opening  the  scrotum  an  enormously  swollen,  turgid  testicle 
was  found  whose  spermatic  cord  was  twisted  to  360  degrees.  Part 
of  the  omentum  was  found  at  the  internal  ring.  The  testicle  was 
untwisted  and  removed,  the  cord  resected  and  the  inguinal  canal 
closed  as  in  herniotomy. 

TORSION  OF  THE  PEDICLE  OF  THE  SPLEEN 

The  pedicle  of  the  spleen  may  become  twisted  in  cases  of  wander- 
ing spleen.  As  in  other  varieties  of  torsion,  it  may  develop  slowly, 
producing  no  marked  symptoms  and  resulting  only  in  congestion  of 
the  organ  and  increase  in  size.  Developing  suddenly  it  is  accom- 
panied by  the  symptoms  of  general  peritonitis  or  intestinal  obstruc- 
tion, and  collapse.  It  may  be  mistaken  for  one  of  these  conditions. 
The  tumor  may  suggest  subphrenic  abscess. 

As  Moynihan  says,  in  the  great  majority  of  cases,  splenectomy 
is  the  better  course  to  pursue,  and  this  is  especially  true  when  throm- 
bosis of  the  splenic  vessels,  infarcts  in  the  spleen,  gangrene  or  peri- 
tonitis upon  or  around  the  spleen  are  present;  when  also  the  organ  is 
enlarged,  it  should  be  removed,  for  even  though  the  pedicle  be  un- 
twisted, it  is  useless  to  try  a  splenopexy. 

The  result  of  fastening  in  place  a  small  w^andering  spleen  is  doubt- 
ful. If  it  is  enlarged,  failure  is  certain.  Fortunately,  as  Hartmann 
has  pointed  out,  a  displaced  spleen  is  usually  not  at  all  difficult  to 
remove  because  the  lengthened  pedicle  permits  of  ready  delivery; 
43 


674    TORSION  OF  THE  PEDICLE  OF  OVARIAN  OR  UTERINE  TUMORS 

and  the  after-effects  are  not  so  serious  as  those  which  attend  removal 
for  organic  disease.     (Splenectomy,  page  550.) 

TORSION  OF  THE  OMENTUM 

Torsion  of  the  omentum  must  naturally  be  a  rare  condition,  and 
yet  is  to  be  thought  of  when  symptoms  of  intestinal  obstruction  arise 
in  those  who  have  a  hernia  or  are  obese. 

Torsion  of  the  omentum  as  might  be  expected  is  very  painful. 
The  pain,  which  is  probably  due  to_^the  plugging  of  the  omental  ves- 
sels, may  simulate  appendicitis.  It  is  not  important  that  the  differ- 
ential diagnosis  is  sometimes  not  made,  for  the  symptoms  indicate 
operation. 

Rinchea  and  Corner  describe  a  case  in  the  British  Medical  Journal, 
Jan.  20,  1906.  The  patient,  a  man  of  forty-eight,  had  had  a  hernia 
for  thirty-seven  years,  and  had  worn  a  truss  for  thirty- three;  the 
hernia  had  been  reducible  and  painless.  He  was  suddenly  seized 
with  pain,  and  the  hernia  became  irreducible.  The  pain  increased, 
and  the  tumor  as  well,  though  after  two  days  the  bowels  moved,  a 
circumstance  which  ruled  out  strangulated  hernia.  The  temperature 
remained  99°,  the  pulse  102.  The  skin  over  the  lower  part  of  the 
abdomen  and  inguinal  region  became  reddened  and  the  region  tender. 
An  incision  over  the  inguinal  canal  found  the  tissues  inflamed,  and 
on  opening  the  hernial  sac  a  small  mass  of  omentum  was  found 
twisted  on  itself  five  times,  but  not  constricted  at  the  internal  ring. 
The  ma^ss  was  resected,  and  the  radical  operation  for  hernia 
performed. 

In  another  case,  the  patient,  a  man  of  forty-five  with  recent  direct 
hernia,  a  mass  of  omentum  was  found,  pedunculated,  the  size  of  a 
walnut,  and  containing  a  hemorrhagic  cyst. 

Cullen,  of  Baltimore  (Johns  Hopkins  Hospital  Bulletin,  Dec, 
1905),  reports  a  case  occurring  in  a  very  heavy  man.  The  patient, 
a  railway  conductor,  had  found  it  necessary  to  eject  a  recalcitrant 
passenger  and  succeeded  only  after  a  struggle.  In  a  few  hours  he 
had  developed  the  symptoms  of  appendicitis. 

At  the  operation  a  gray,  vascular,  nodulated  mass  was  found 
which  ended  above  in  a  tightly  twisted  pedicle  and  which  on  removal 
proved  to  be  the  omentum. 


CHAPTER  XVII 
RUPTURE   AND    HEMORRHAGE    OF   TUBAL   PREGNANCY 

Rupture  of  the  sac  of  an  ectopic  gestation  is  far  from  being  a  rare 
accident  (Fig.  518),  When  it  occurs,  it  is  a  major  emergency,  one  in 
which  the  doctor,  isolated  though  he  may  be,  must  act  and  without 
delay.  Eighty-five  per  cent,  of  these  cases  operated  upon  recover; 
85  per  cent,  of  those  treated  by  expectancy  die.  These  figures 
are  in  themselves  sufi&cient  argument,  but  when  we  add  that  the 


Fig.  518. — Ruptured  tubal  pregnancy.      Clot  protruding  from  sac.      (Montgomery.) 


gravity  of  the  condition  grows  out  of  hemorrhage,  the  reason  for  im- 
mediate intervention  must  be  admitted  by  all.  Even  in  case  the 
hemorrhage  tends  to  cease  spontaneously,  the  urgency  is  scarcely 
less  pressing  to  prevent  injection.  For,  from  a  diseased  tube  or  a 
stagnant  fecal  current,  bacteria  may  escape  to  find  a  culture  medium 
in  the  blood  free  in  the  peritoneal  cavity. 

That  the  diagnosis  of  an  extra-uterine  pregnancy,  even  when  sus- 
pected, is  difficult,  no  one  will  deny.  After  the  most  careful  exam- 
ination, one  may  not  avoid  error.  More  often,  the  condition 
is  not  even  suspected  until  rupture  occurs. 

67s 


676  RUPTURE    AND   HEMORRHAGE    OF   TUBAL   PREGNANCY 

A  tubal  pregnancy  may  be  unrecognized,  but  there  can  be  no 
excuse  for  overlooking  a  ruptured  tubal  pregnancy.  It  can  scarcely  be 
mistaken  for  anything  else.  Even  if  we  admit  that  exact  diagnosis 
may  be  impossible,  yet  the  indications  for  intervention  are  unmis- 
takable. And  that,  after  all,  is  the  important  thing.  One  does  not 
do  grave  emergency  operations  on  mere  impressions  or  suspicions 
or  the  fear  that  such  and  such  may  be  the  case.  We  must  have  a 
clear  clinical  picture  in  mind. 

The  attack  comes  on  suddenly.  There  are  pain,  shock  from  the 
peritoneal  tear,  and  vomiting,  suggestive  of  acute  intestinal  obstruc- 
tion. One  might  also  think  of  appendicitis  or  a  renal  calculus. 
There  is  often  a  bloody  uterine  discharge.  Brickner  says  of  the  pain 
that  it  is  usually  localized  over  the  site  of  the  lesion.  It  has  no 
definite  character;  it  may  be  cramp-like  over  the  affected  tube;  it  may 
simulate  labor  pains;  it  may  be  sharp  and  sudden.  The  usual  symp- 
toms of  pregnancy  may  be  present,  but  their  absence  does  not  argue 
against  the  extra-uterine  pregnancy.  We  have,  as  yet,  no  definite 
data  by  which  we  differentiate  between  the  various  forms  (]\Iedical 
Standard).  The  history  of  the  case  and,  finally,  the  signs  of  progress- 
ive internal  hemorrhage  point  to  the  nature  of  the  accident.  The 
pulse  grows  more  rapid  and  feeble,  the  temperature  falls,  the  features 
are  blanched,  dyspnea  appears  and  all  the  symptoms  of  collapse. 
Vaginal  examination  completes  the  diagnosis.  One  may  find  the 
uterus  but  little  enlarged,  but  on  one  side  or  the  other,  rising  out  of 
the  retro-uterine  pouch,  a  boggy  mass  of  variable  size  is  felt.  DLxon, 
of  St.  Louis  (Interstate  Medical  Journal),  says  that  in  fifteen  cases,  he 
found  the  pregnancy  on  the  right  side  in  all  but  one,  and  this  patient 
had  the  peculiar  fortune  to  have  one  on  both  sides.  The  right  side 
was  relieved  by  operation,  and  six  months  later  the  left  side  necessi- 
tated a  second  operation.  Dixon  adds  that  rigidity  of  the  abdomi- 
nal walls  was  present  in  most  of  these  cases,  though  the  absence  of 
rigidity  is  often  named  as  a  differential  diagnostic  point. 

There  may  be  an  element  of  confusion.  Vineberg,  of  New  York 
(New  York  Med.  Jour.,  Feb.  22,  1906),  reports  two  cases  out  of  his 
fifty-three  in  which  there  was  a  combined  intra-  and  extra-uterine 
pregnancy.  He  notes  that  a  persistence  of  uterine  bleeding  after  an 
operation  for  extra-uterine  pregnancy  should  suggest  the  possibility 


OPERATIVE   TECHNIC  677 

of  an  intra-ulerine  gestation.  He  adds,  with  respect  to  diagnosis  of 
the  condition  generally,  that  amenorrhea,  followed  later  by  pain  and 
irregular  uterine  bleeding,  should  always  put  one  on  his  guard. 

From  the  history,  then,  and  from  the  physical  examination  one 
must  diagnose  the  condition.  On  the  signs  of  progressive  internal 
hemorrhage  the  decision  to  operate  immediately  is  based,  and  one 
should  scarcely  ever  deem  it  too  late,  for  even  in  the  face  of  the  most 
menacing  conditions,  we  must  hold  bravely  to  the  last  resource  in 
which,  even  in  the  desperate  cases,  there  is  often  safety  and  life. 

Operation. — -As  Lejars  says,  the  operation  is  moving  and  dramatic, 
but  presents  no  especial  difficulties  if  one  but  keeps  cool  and  knows 
what  is  to  be  done. 

Instrimients — 'The  instruments  necessary  are  scalpel,  scissors, 
artery  forceps,  two  long  clamp  forceps,  two  retractors,  and  curved 
needles. 

General  Anesthesia. — 'General  anesthesia  is  necessary  and  must  be 
closely  watched.  A  continual  hypodermoclysis  is  an  excellent  means 
of  combating  the  combined  effects  of  shock  and  anesthesia.  It 
should  not  be  begun,  however,  until  the  hemorrhage  has  been 
controlled. 

Antisepsis. — It  is  scarcely  necessary  to  say  that  it  is  of  little  use  to 
save  the  patient  from  hemorrhage  to  die  a  few  days  later  from  sepsis. 
The  peritoneal  cavity,  under  the  conditions  assumed,  is  a  dangerous 
culture  medium. 

The  Trendelenburg  position  is  almost  indispensable,  and  if  neces- 
sary may  be  improvised. 

Incision. — -A  median  incision  extending  from  the  umbilicus  toward 
the  pubes  is  made.  Do  not  wound  the  bladder,  which  may  be 
pushed  upward  and  forward.  This,  however,  is  not  particularly 
serious  unless  the  wound  should  be  overlooked.  Waste  no  time.  As 
soon  as  the  peritoneum  is  opened,  catch  its  edges  with  artery  forceps 
and  enlarge  the  orifice  upward  and  downward.  Do  not  try  to  sponge 
out  the  cavity.  Without  regarding  the  clots,  which  may  mask  the 
viscera,  plunge  a  hand  into  the  pelvic  cavity  and  locate  the  uterus, 
which  is  easily  recognized.  To  one  side,  a  thick,  doughy  or  friable 
mass  will  be  felt.  Slip  your  fingers  under  it,  break  the  adhesions,  and 
enucleate  it.     This  will  empty  the  retro-uterine  pouch — the  cul-de- 


678     RUPTURE  AND  HEMORRHAGE  OF  TUBAL  PREGNANCY 

sac  of  Douglas.  Feel  with  finger  and  thumb  for  the  pedicle  and,  if 
possible,  pull  the  entire  mass  up  into  the  wound  and  clamp.  If  the 
mass  is  not  adherent,  a  single  clamp  enclosing  the  broad  Hgament 
from  the  outer  side  and  passing  under  to  include  the  tube  will  suffice 
(Fig.  519).  If  there  is  too  much  adhesion,  clamp  on  either  side 
of  the  pedicle.  When  the  clamps  are  placed,  the  chief  end  of  the 
operation  has  been  attained.  Do  not  waste  time  trying  to  catch  the 
bleeding  points,  but  ligate  en  masse. 


Fig.  519. — Forceps  applied  to  the  tubo-ovarian  pedicle.     Trendelenburg  position.     (Ffflw.) 

Ligate  the  pedicle.  With  a  blunt,  curved  needle  armed  with  No.  3 
catgut,  transfix  the  pedicle  close  to  the  cornu  of  the  uterus,  between  :t 
and  the  forceps  (Fig.  520).  Ligate  and  then  carry  the  ligature 
around  the  lower  segment  of  the  pedicle  and  tie  again,  directing  the 
assistant  to  pull  up  on  the  clamp,  and  finally  carry  the  ligature 
around  the  entire  mass  and  tie  a  third  time.  Preserve  the  ends  of 
the  ligature.  Resect  the  tumor  and  Hft  up  the  stump  by  means 
of  the  threads  to  see  if  there  is  any  bleeding  (Fig.  521).  This  ligature 
stands  between  the  patient  and  death.  If  two  clamps  have  been 
used,  it  will  be  necessary  to  ligate  ^'  en  chaine.'^ 


OPERATIVE   TECHNIC  679 

Now  clean  out  the  clots,  mop  out  the  blood,  and  lower  the  pelvis  to 
drain  the  upper  part  of  the  abdominal  cavity.  The  quantity  of 
blood  is  often  enormous.  If  the  patient  is  very  weak,  do  not  prolong 
the  task  of  cleansing  it  all  out;  yet  in  the  long  run,  it  is  better  to  take 
the  time  to  cleanse  out  the  fossa  and  wipe  the  intestine  and  omentum, 
for  then  the  abdomen  may  be  closed  without  drainage. 


Fig,  520. — First  ligature  applied.      (^Veau.) 

Drainage.  If  there  is  oozing,  apply  a  gauze  drain  at  the  site  of  the 
tumor,  and  insert  three  or  four  drainage-tubes  into  different  parts  of 
the  cavity  to  carry  out  the  blood  left  behind.  Do  not  forget  to  fix 
the  drains,  lest  they  be  lost  in  the  abdomen. 

Suture  the  wound  partially,  unless  able  to  dispense  with  drainage, 
in  which  case  suture  completely.  Apply  a  dry  dressing  of  gauze  and 
absorbent  cotton.  Inject  salt  solution.  After  twelve  hours,  change 
the  dressing,  which  will  probably  be  saturated;  thereafter  change 
daily.  About  the  seventh  day  the  tubes  may  be  shortened,  and 
about  the  fifteenth  day,  or  often  sooner,  altogether  removed. 

Interstitial  tubal  pregnancy  (Fig.  522)  may  occasionally  be  met 
with  and  present  compUcations.    A  case  described  by  O.  G.  Pfaff,  of 


68o 


RUPTURE    AND   HEMORRHAGE    OF   TUBAL   PREGNANCY 


Indianapolis  (Western  Clinical  Recorder,  March,  1903)  illustrates 
the  subject.  On  opening  the  abdomen  a  large  reddish  bag  presented, 
which  seemed  to  develop  from  the  right  wall  of  the  uterus,  involving 


Fig.  521. — Ligation  and  division  of  the  tubo-ovarian  pedicle.      (Veau.) 


«fU, 


Fig.  522. — Tubo-ovarian  pregnancy.     (Montgomery.) 

the  right  tube.  In  order  to  minimize  the  hemorrhage  as  well  as  to 
secure  the  tumor,  the  upper  portion  of  the  broad  ligament  was 
clamped  and  another  clamp  placed  to  the  left  of  the  tumor  passing 


OPERATIVE    TECHNIC  68l 

obliquely  across  the  fundus  and  including  the  uterine  artery.  The 
sac  was  now  incised  at  its  summit  and  the  fetus,  membranes,  and 
placenta  turned  out.  No  ligatures  were  required.  The  sac  was 
partially  sutured,  a  drainage-tube  fastened  in  its  cavity  and  brought 
out  through  the  lower  angle  of  the  abdominal  wound.  The  drainage- 
tube  was  removed  on  the  fifth  day,  and  recovery  was  complete. 

In  certain  of  these  cases  the  hemorrhage  may  be  very  difficult  to 
control.  A  "V"  shaped  section  from  the  uterus  in  the  region  of  the 
cornua  with  firm  suturing  may  succeed. 

Finally  in  more  obdurate  cases  a  hysterectomy  may  be  necessary. 


CHAPTER  XVIII 
CESAREAN  SECTION 

Cesarean  section,  designed  primarily  as  an  operation  to  save  the 
babe  after  the  mother's  death,  is  to-day  of  far  broader  application. 
Without  considering  its  exact  indications,  which  for  that  matter  the 
whole  profession  is  not  yet  agreed  upon,  it  may  be  stated  broadly 
that  it  is  the  method  of  choice  when  the  child  cannot  otherwise  be 
delivered  alive.  Unfortunately  at  the  present  time  it  is  usually  what 
it  should  not  be,  viz.,  an  emergency  operation. 

The  Technic  of  Operation.  First  Stage:  Laparotomy. — Incise 
the  abdominal  wall.  The  incision  extends  in  the  middle  hne  to 
within  2  inches  of  the  pubes  and  should  be  at  least  4  inches  in  length. 
If  the  uterus  is  to  be  brought  out  of  the  abdominal  wound  it  will  re- 
quire to  be  longer.  The  peritoneum  is  to  be  exposed  and  opened  up 
in  the  usual  manner.  The  abdominal  w^alls  are  often  quite  thin. 
As  soon  as  the  peritoneum  is  opened  the  uterus  pushes  into  view. 
Correct  any  lateral  deviation.  Hurriedly  wall  off  the  uterus  with 
sterile  compresses,  or  deliver  the  uterus,  protect  with  sterile  com- 
presses and  suture  the  upper  angle  of  the  peritoneal  wound. 

Second  Stage:  Incision  of  the  Uterus. — Keep  exactly  in  the  middle 
Une.  Make  a  small  incision  in  the  uterus  at  the  level  of  the  lower 
end  of  the  abdominal  wound  that  you  may  not  later  encroach  upon 
the  lower  segment  of  the  uterus. 

The  peritoneum  and  superficial  muscular  layers  are  divided  with 
the  bistoury,  the  deeper  muscular  fibers  separated  with  the  fingers. 
Make  a  small  opening  in  the  mucous  membrane.  Through  this 
wound  slip  a  finger  into  the  uterus  and  on  it  as  a  guide  divide  the 
uterine  wall  with  scissors  toward  the  summit;  the  incision  should  be 
6  or  7  inches  long.  If  the  placenta  is  attached  over  the  median  line, 
cut  through  it  also.  It  makes  no  difference  if  the  work  is  done 
rapidly. 

682 


OPERATIVE   TECHNIC  683 

Third  Stage:  Deliver  the  Child. — Slip  the  hand  into  the  uterus. 
Grasp  the  feet,  delivering  the  breech  first.  Clamp  the  cord  in  two 
places  and  cut  between. 

Fourth  Stage:  Remove  the  Membranes. — As  soon  as  the  child  is 
delivered  the  uterus  contracts  and  often  the  placenta  is  detached  at 
once.     If  not  it  must  be  peeled  off  with  the  fingers. 

Fifth  Stage:  Suture  the  Uterus. — 'Repair  the  uterine  wall  with  7  or  8 
interrupted  catgut  sutures  deeply  placed  but  not  reaching  the  mu- 
cosa; or  suture  the  mucosa  first.  Complete  the  repair  by  a  few 
superficial  sutures.  Suture  is  the  best  means  of  hemostasis,  but 
the  bleeding  is  usually  inconsiderable,  especially  if  the  uterus  is 
brought  outside  and  bent  toward  the  pubes. 

Sixth  Stage:  Suture  the  Abdominal  Wall. — Repair  the  peritoneum 
with  continuous  suture;  the  fascias  with  chromic  gut  or  plain 
catgut;   the  skin  with  silkworm-gut. 

These  are  the  principles  involved,  bared  of  details  which,  of  course, 
vary  with  the  operator  and  with  the  environment.  Examples  are  not 
wanting  in  current  literature.  A  few  will  serve  to  bring  out  practical 
points'. 

Lanphear,  of  St.  Louis  (American  Jour.  Surgery,  Dec,  1906), 
formulates  a  technic  for  country  practice.  The  operator  should  have 
a  physician  for  assistant,  or  a  trained  nurse.  The  anesthetic  should 
be  given  by  a  physician. 

Instruments. — -Vaginal  retractor  (for  cleansing  the  vagina),  knife, 
scissors,  4  hemostats,  needles,  chromic  catgut  No.  2,  silkworm-gut, 
safety-pins. 

The  cojitainers  for  the  solutions  must  be  boiled  and  singed  with 
burning  alcohol — ^one  for  bichloride,  i  to  2000.  one  for  alcohol,  and  one 
for  sterile  water,  a  small  dish  or  two  for  the  instruments. 

Dressings  and  Sponges. — -Boil  15  yards  of  gauze  and  12  towels  free 
from  fringes. 

Preparation  of  Patient. — Pubes  and  vulva  shaved.  Abdomen 
scrubbed.  When  the  anesthesia  is  complete  scrub  the  vagina  with 
gauze  and  soap  and  water,  followed  by  alcohol. 

Preparation  of  the  H  and  s . — ^They  are  to  be  scrubbed  for  five  minutes 
before  disinfecting  the  patient  and  for  five  minutes  after,  followed 
by  immersion  in  alcohol  and  then  in  the  bichloride  solution.     Again 


684  CESAREAN    SECTION 

sponge  the  abdomen  before  covering  the  field  with  four  sterile  towels 
fastened  with  sterile  safety-pins. 

Abdominal  Incision. — -Deliver  the  uterus  and  surround  with  four 
towels  wrung  out  of  very  hot  water.  Protect  the  edges  of  the  wound 
with  sterile  towels  packed  in  around  the  uterus. 

Incise  the  uterus;  deliver  the  child;  clamp  and  cut  the  cord.  The 
anesthetist  may  now  look  after  the  child  if  there  is  no  one  else  to  do  so. 
Be  careful  in  handling  the  child  that  your  hands  do  not  come  in  con- 
tact with  anything  not  sterile.  Deliver  the  placenta,  mop  out  the 
uterus;  suture.  Lanphear  advises  a  final  row  of  Lembert  sutures  for 
the  peritoneal  covering  of  the  uterus.  Repair  the  abdominal  wall; 
dress  as  usual;  pack  the  vagina  lightly  and  treat  subsequently  as 
after  any  other  confinement.  Brown,  of  Manchester,  N.  H.,  recom- 
mends practically  the  same  procedure  (American  Jour.  Surgery, 
Feb.,  1907).  He  observes  that  the  uterus  should  be  kneaded  for  a 
moment  to  stimulate  contraction.  He  uses  in  suturing  the  uterine 
wall,  a  row  of  twenty-day  chromicized  gut  sutures,  passing  through 
all  the  layers  a  second  row  of  Lembert  sutures  of  silk. 

Paul  Martin,  of  Indianapolis,  reports  a  case  (Medical  Record,  Oct. 
27,  1906).  Operated  after  twelve  hours  of  labor  complicated  by 
eclampsia  and  a  narrow  pelvis  and  in  which  the  bladder  was  greatly 
distended  and  which  could  not  be  emptied  by  catheter.  The  bladder 
extended  half-way  to  the  umbilicus.  The  uterus  was  emptied  through 
a  4-inch  incision"  and  the  bleeding  controlled  by  the  assistant  who 
grasped  the  cervix.  The  uterine  sutures  employed  by  Martin  were  a 
double  row  of  interrupted  muscular  sutures  of  chromic  gut  and  a 
continuous  chromic  gut  for  the  serous  coat.  The  bladder  was 
not  injured  and  afterward  easily  emptied.  Mother  and  child  both 
survived. 

S.  A.  Reynolds  (Gaillards  Southern  Medicine,  Feb.,  1905)  reports 
an  operation  which,  as  he  says,  illustrates  the  principle  that  we  should 
never  be  afraid  to  put  forth  an  effort  to  relieve  our  patients  when 
absolutely  demanded,  however  hazardous  and  difficult  the  inter- 
vention and  however  meager  the  means  at  our  command.  Place, 
a  log  cabin  with  one  room,  lighted  by  a  lamp  without  chimney. 
Patient,  a  colored  girl  of  thirteen  with  pelvic  diameters  less  than  2 
inches;  labor  for  twelve  hours  with  a  midwife  in  attendance.     Both  he 


OPERATIVE   TECHNIC  685 

and  Dr.  Keen,  willi  whom  he  consulted,  realized  the  urgency,  but 
neither  had  ever  done  a  laparotomy.  Their  equipment  consisted  of  two 
pocket  cases  of  instruments,  carbolic  acid,  a  few  ligatures,  an  earthen 
pitcher  and  bowl,  with  teakettle  of  hot  water.  They  sterilized  their 
instruments  and  hands  in  carbolic  solution.  Patient  was  laid  across 
the  bed  with  feet  on  the  floor.  The  abdomen  washed.  While  Dr. 
Keen  gave  the  chloroform  Reynolds  made  an  incision  from  the 
umbilicus  down.  The  sides  of  the  abdomen  were  pressed  against 
the  sides  of  the  uterus  to  prevent  bleeding  into  the  abdominal 
cavity,  and  the  uterus  opened  and  emptied. 

One  suture  was  put  in  the  uterus.  Abdominal  wall  closed  with 
silk.  On  the  fourth  day  the  temperature  was  103.5°,  pulse  150,  resp. 
36,  but  the  symptoms  of  infection  subsided  and  by  the  fourth  week 
the  patient  was  well. 


CHAPTER  XIX 
RUPTURE  OF  THE  URETHRA^ 

By  a  fall  astride  a  hard  or  sharp-margined  object,  by  accidents  of 
saddle  or  bicycle,  by  a  kick  or  blow,  by  a  fracture  of  the  pelvis,  the 
urethra  may  be  ruptured.  The  urethral  canal  is  forced  up  against 
the  pubic  arch  or  against  the  sharp  edge  of  the  triangular  ligament, 
and  is  lacerated  while  the  more  elastic  integument  of  the  perineum 
escapes. 

Any  part  of  the  urethra  may  suffer,  although  usually  only  one  part 
is  involved  in  a  given  case.  The  prognosis,  and  in  some  degree  the 
treatment,  depend  upon  the  portion  injured,  though  the  exact  loca- 
tion is  not  always  easily  determined. 

Again  the  prognosis  and    treatment    depend  upon  whether  the 

^  "  We  consider  it  unnecessary  to  speak  of  the  medical  treatment  which  is  abso- 
lutely valueless,  and  while  the  mechanical  treatment  has  been  in  favor  even  with 
the  surgeon,  it  must  be  condemned  if  it  becomes  a  general  procedure. 

The  introduction  of  sounds  and  catheters  into  a  lacerated  urethra  will  almost 
invariably  be  followed  by  infection  at  the  point  of  laceration,  notwithstanding  the 
aseptic  conditions  under  which  the  catheterization  is  performed.  The  general 
practitioner  has  been  accused  of  inefficiency  and  carelessness  in  sterilizing  his  in- 
struments. While  this  is  true  to  some  extent,  it  will  be  seen  later,  when  speaking 
of  the  Bacteriology  of  the  Urethra,  that  a  small  aseptic  instrument  may  cause 
infection  because  the  traumatism  produced  by  the  passage  of  a  sound  increases 
the  virulence  of  the  urethral  flora,  which  normally  is  in  a  semi-saprophytic 
state  of  life. 

On  the  other  hand,  the  general  practitioner  with  less  ability  in  the  handling  of 
sounds,  especially  when  the  urethra  is  inflamed  and  edematous,  will  cause  false 
passages,  increase  the  liability  of  stricture  at  the  point  of  laceration  and  predis- 
pose the  deep  structures  to  infection  and  its  consequences.  It  is  our  object  to 
urge  early  surgical  treatment  in  these  cases  and  rational  treatment  of  the  later 
consequences.  The  expression,  "traumatic  stricture,"  must  disappear  from  the 
medical  vocabulary  if  the  intervention  in  acute  cases  be  immediate  and  rational." 
— Surgery,  Gynecology,  Obstetrics,  Oct.,  1906.  Neff  and  Schrayer,  Murphy's 
Clinic,  Chicago. 

686 


DIAGNOSIS    OF   RUPTURE  687 

rupture  is  total  or  incomplete,  for  upon  the  degree  of  laceration 
depend  the  rapidity  of  extravasation  and  later  the  dimensions  of 
the  stricture. 

These,  then,  are  the  dangers:  extravasation  of  urine,  and  in  its 
wake  suppuration,  abscess  formation,  and  general  septic  infection; 
on  the  other  hand  and  later,  stricture  formation  and  all  its  attendant 
difficulties. 

Rupture  of  the  urethra,  therefore,  is  always  a  serious  injury,  and  in 
order  that  its  dangers  may  be  obviated,  promptness  of  recognition 
and  intervention  is  imperative. 

The  symptoms  of  injury  to  the  urethra  are  definite  though  varying 
in  degree  and  are:  retention  of  urine,  hemorrhage  from  the  urethra, 
and  perineal  tumor. 

These  symptoms,  together  with  the  history  of  the  case,  readily 
make  the  diagnosis,  but  only  by  a  careful  study  of  each,  recalling  at 
the  same  time  the  anatomy  of  the  urethra,  may  one  decide  upon  the 
location  of  the  injury. 

(a)  Retention  of  urine  accompanies  in  some  degree  all  traumatic 
ruptures,  though  one  should  not  make  a  diagnosis  from  this  symp- 
tom alone  for  retention  may  follow  a  mere  contusion — an  interstitial 
rupture,  without  any  solution  of  the  continuity  of  the  canal  and  with- 
out obstruction.  It  has  its  origin  in  "shock,"  perhaps,  with  tem- 
porary paralysis  of  the  bladder  musculature.  In  such  a  case,  there 
is  gradual  development  of  a  perineal  tumor  from  the  contusion,  but, 
on  the  other  hand,  the  bladder  slowly  fills  and  rises  out  of  the  pelvis. 

In  a  few  hours,  the  urine  begins  to  dribble;  a  little  later  micturition 
becomes  voluntary  though  painful,  and  gradually  the  function  is  re- 
stored to  the  normal.  In  actual  rupture,  the  retention  is  complete 
and  continuous. 

(b)  Hemorrhage  from  the  urethra  is  indicative  of  rupture,  but  its 
amount  in  nowise  points  to  the  degree  of  urethral  destruction.  No 
inference  may  be  drawn  from  it  as  to  the  severity  of  the  lesion.  In 
fact,  the  slighter  the  hemorrhage,  the  worse  the  outlook  if  the  other 
symptoms  are  aggravated.  For  instance,  if  the  mucous  membrane 
alone  is  torn,  the  hemorrhage  is  immediate,  perhaps  voluminous,  and 
yet  the  lesion  is  of  minor  importance.  On  the  other  hand,  if  the 
rupture  is  complete,  the  blood  pours  out  into  the  lacerated  tissues  of 


688  RUPTURE  OF  THE  URETHRA 

the  perineum,  and  only  a  few  drops  may  find  their  way  through  the 
occluded  canal.  Therefore,  one  must  never  conclude  that  because 
the  hemorrhage  from  the  meatus  is  slight,  the  injury  is  slight. 

(c)  Perineal  Tumor. — There  is  always  swelling  in  some  degree  fol- 
lowing contusions  of  the  perineum  w^hether  the  urethra  is  injured  or 
not.  The  perineal  and  scrotal  tissues  are  ecchymosed  and  the 
scrotum  especially  is  likely  to  be  engorged  with  exudates.  If  the 
urethra  is  ruptured  the  bladder  empties  itself  into  the  bruised  perineal 
tissues,  the  ecchymosis  rapidly  becomes  an  edema,  gradually  thicken- 
ing and  expanding.  It  is  at  tirst  an  ovoid  swelling  in  the  middle  of 
the  perineum,  but  gradually  spreads  until  the  scrotum,  the  pelvis,  and 
finally  the  abdominal  walls  are  infiltrated,  thickened  or  edematous  to 
a  marked  degree.  But  do  not  forget  that  the  absence  of  a  perineal 
tumor  does  not  always  mean  that  the  injury  is  slight.  If  the  rupture 
is  situated  behind  the  anterior  layer  of  the  triangular  ligament  and  if 
this  is  not  torn,  the  transudates  cannot  reach  the  perineum,  for  this 
tendinous  band  limits  the  forward  movement  of  the  urine;  and  so, 
taking  the  direction  of  least  resistance,  it  percolates  through  the  cellu- 
lar tissues  of  the  pelvic  cavity  and  passes  up  along  the  side  of  the 
bladder  to  the  abdominal  wall.  Since,  however,  the  anterior  layer  of 
the  triangular  ligament  is  nearly  always  torn  to  some  extent,  peri- 
neal swelling  is  nearly  ahvays  present.  Slight  swelling  will  give  no 
feeling  of  security  that  the  injury  is  slight.  It  is  obviously  essential 
that  one  must  have  clearly  in  mind  the  anatomy  of  the  urethra. 

THE  AXATO^lY  OF  THE  URETHRA 

Stretched  across  the  anterior  segment  of  the  pelvic  outlet,  between 
the  rami  of  the  pubes,  is  the  triangular  ligament,  dense  and  fibrous, 
and  arranged  in  two  layers,  separated  by  a  J^-inch  space.  In 
contact  with  the  deep  or  pelvic  surface  of  the  triangular  ligament,  is 
the  apex  of  the  prostate  gland.  In  contact  with  the  superficial  or  peri- 
neal surface  is  the  bulb  of  the  urethra,  the  knobbed  posterior  ex- 
tremity of  the  corpus  spongiosum.  The  urethra  traverses  the  pros- 
tate, perforates  and  bridges  the  space  between  the  two  layers  of  the 
triangular  ligament  and  then  tunnels  the  bulb,  runs  the  length  of  the 
corpus  spongiosum,  and  emerges  at  the  glans  penis,  the  anterior 


TREATMENT    OF    CONTUSION  689 

knobbed  extremity  of  the  corpus  spongiosum.  The  part  of  the  ure- 
thra anterior  to  the  triangular  ligament  consists,  then,  of  two  por- 
tions, the  penile  and  bulbous;  the  deep  urethra  of  two,  the  prostatic 
and  membranous,  which  later  is  the  part  which  bridges  the  y^- 
inch  space  between  the  two  layers  of  the  triangular  ligament.  The 
clinical  manifestations  of  rupture  depend  upon  whether  the  bulb- 
ous or  membranous  portion  is  involved  and  in  a  minor  degree  upon 
whether  the  rupture  is  partial  or  complete,     (See  Y\g.  546.) 

CONTUSION  OF  THE  BULBOUS  PORTION 

Injury  to  the  bulbous  portion  is  by  far  the  more  frequent;  it  is  the 
form  which  the  practitioner  will  nearly  always  find.  It  remains  for 
him  to  decide 'w^hether  the  injury  is  a  contusion  or  rupture,  for  the 
prognosis  and  treatment  are  quite  different  in  the  two  degrees  of 
injury.  If  the  case  is  one  of  contusion,  it  is  likely  the  hemorrhage 
was  abundant;  the  patient  complains  of  pain  and  inability  to  pass 
water;  there  is  no  perineal  tumor  though  the  tissues  may  be  much 
bruised.  After  a  few  hours  he  begins  to  pass  water  after  painful 
effort.  The  urethral  bleeding  may  persist,  but  the  bladder  keeps  well 
emptied. 

Treatment. — ^The  treatment  is  very  simple.  Keep  the  patient 
quiet,  relieve  the  pain  if  necessary  with  small  doses  of  morphine,  and 
give  some  urinary  antiseptic  such  as  urotropin. 

Do  not  pass  a  catheter.  Why  should  you. ^  The  bladder  empties 
itself;  there  is  no  perineal  infiltration;  and  to  do  so  would  only 
increase  the  risk  of  infection.  The  normal  micturition  will  return  in 
a  few  days  in  the  cases  of  mild  contusion,  and  perhaps  in  a  week  the 
patient  will  be  well.  If,  however,  in  such  a  case,  after  a  few  days  mic- 
turition should  become  more  painful  and  finally  impossible,  due  to 
urethral  swelling  or  spasm,  catheterization  is  indicated.  Try  a  large, 
soft,  aseptic  catheter  first;  try  to  carry  it  gently  along  the  upper 
wall  of  the  urethra.  You  may  fail  and  be  forced  to  fall  back  on  a 
catheter  of  small  size,  but  in  no  case  must  violence  be  used  or  the 
attempts  prolonged.  The  catheter  may  be  left  in  if  the  introduction 
was  difficult,  but  it  must  be  kept  under  constant  surveillance,  and  at 
the  first  appearance  of  a  perineal  tumor,  indicative  of  infiltration, 

44 


690  RUPTURE  OF  THE  URETHRA 

Operation  is  imperative.  If  a  catheter  of  small  size  has  to  be  em- 
ployed, it  may  not  fill  the  urethra  and  there  may  be  some  dribbling  of 
urine,  which  favors  infection.  In  such  a  case  the  catheter  remaining 
in  the  bladder  may  keep  it  empty  by  siphonage. 

Contusion,  with  the  formation  of  a  large  hematoma  in  the  peri- 
neum, might  simulate  rupture,  but  the  presence  of  a  distended  blad- 
der demonstrates  that  the  perineal  tumor  is  not  infiltrated  urine. 
In  such  a  case  again,  an  attempt  should  be  made  to  pass  a  catheter  if 
the  urine  does  not  begin  to  flow  after  three  or  four  hours.  If  suc- 
cessful, the  size  of  catheter  may  be  increased  from  day  to  day. 

It  must  be  borne  in  mind  in  making  the  first  attempt  that  too  per- 
sistent effort  may  result  in  rupture  of  the  already  contused  urethra, 
or  insure  infection. 

In  case  of  failure,  you  may  follow  the  recommendation  of  Lejars, 
and  proceed  to  drain  the  bladder  by  suprapubic  puncture  and  it  may 
be,  after  a  day  or  two  when  the  swelling  has  subsided,  a  catheter  can 
be  passed  and  drainage  secured  in  that  manner  as  before,  but  hold 
yourself  ready  to  operate  at  the  first  sign  of  infiltration. 

This  line  of  treatment  can  only  be  recommended  to  those  who  are 
sure  they  can  distinguish  between  hematoma  following  contusion  and 
infiltration  following  rupture.  In  case  of  doubt,  always  treat  the 
case  as  one  of  rupture. 

RUPTURE  OF  THE  BULBOUS  PORTION 

« 

Urethral  hemorrhage,  rapidly  increasing  perineal  tumor  obviously 
due  to  infiltrating  urine,  and  retention  of  urine  following  injury  point 
at  once  to  some  destruction  of  the  urethral  wall. 

There  is  no  use  of  wasting  time  attempting  to  pass  a  catheter; 
prepare  at  once  for  an  external  urethrotomy.  Even  if  you  succeed 
in  passing  a  catheter,  it  will  not  prevent  extravasation  in  the  end,  as 
Reginald  Harrison  and  others  have  pointed  out.  Nor  is  there  need 
to  wait  for  additional  symptoms.  The  indications  for  operation  are 
unmistakable.  Delay  merely  exposes  the  patient  to  all  the  risks  of 
infection.  The  end  in  view  is  to  furnish  a  free  outlet  for  the  urine 
and  if  possible  to  repair  the  ruptured  canal. 


OPERATIVE   TECHNIC 


691 


Operation  for  External  Urethrotomy. — ^Provide  for  the  operation 
soft  rubber  catheters  of  various  sizes;  a  grooved  staff  or  steel  sound; 
small,  curved  needles,  silk  No.  o,  and  three  or  four  sizes  of  catgut. 

General  anesthesia  is  indispensable.  Place  the  patient  in  the 
lithotomy  position  with  the  perineum  exposed  to  a  good  light.  The 
entire  field  must  be  disinfected  with  extreme  care. 

As  soon  as  the  patient  is  anesthetized,  an  effort  may  be  made  to 
pass  a  catheter,  and,  if  successful,  the  operation  will  be  greatly  facili- 
tated.    Otherwise  pass  the  guide  as  deeply  as  possible  without  using 


II     iiiiliiniillli 


,N .  \^#4/ 


Fig.  523. — Incision  exposing  the  bvilb  of  the  urethra.     {Duval.) 


force,  and  let  it  be  held  in  position  by  an  assistant  who  also  supports 
the  scrotum. 

The  median  incision  extends  from  the  base  of  the  scrotum  to  within 
an  inch  of  the  anus.  Divide  the  skin  and  fascia,  when  you  may 
reach  an  area  filled  with  clots  and  lacerated  tissues,  the  site  of  the 
bulb  and  its  muscular  coverings  (Fig.  523).  You  may  not  be  able 
to  recognize  the  bulb  if  the  destruction  has  been  great,  but  after 
wiping  out  the  clots  and  debris,  a  cavity  is  exposed  (Fig.  524).  Ex- 
pose the  point  of  the  guide,  and  you  have  thus  located  the  opening 


692 


RUPTURE    OF    THE    URETHRA 


into  the  distal  half  of  the  urethra.  Determine  the  nature  of  the 
urethral  tear,  whether  partial  or  complete.  The  subsequent  pro- 
cedure will  depend  largely  upon  the  t\^e  of  injury  present. 

(a)  If  you  find  rupture  of  the  lower  wall  only,  the  remnant  of  the 
upper  wall,  a  mere  band  perhaps,  will  be  a  great  help  in  the  next 
step,  which  is  to  locate  the  orifice  of  the  urethra  on  the  farther  side 
of  the  tear.  The  search  for  this  opening  must  be  patient  and  minute. 
Let  the  point  of  a  probe  or  grooved  director  follow  the  remnant  of  the 


Fig.  524. — The  muscular  and  erectile  tissue  of  the  bulb  divided,   exposing 
the  urethra.      {Duval.) 


upper  wall  backward  and  it  may  haply  engage  in  the  orifice  and  pass 
on  into  the  bladder;  if  it  does  not,  every  bit  of  the  mangled  tissue 
must  be  examined. 

Another  maneuver  may  be  tried:  if  you  have  a  soft-rubber  catheter 
in  the  urethra,  pull  it  down  into  the  wound  and  endeavor  to  engage 
its  point  in  the  hidden  orifice.  Once  the  orifice  is  found  and  the 
catheter  carried  into  the  bladder,  try  to  suture  the  urethral  wound 
over  the  catheter.  Place  lateral  sutures  of  fine  silk  or  catgut,  begin- 
ning at  the  upper  wall  and  suturing  toward  the  lower  where  the 


OPERATIVE   TECHNIC 


^'93 


separation  is  greatest.  If  possible,  pass  the  suture  through  the  outer 
coats  only. 

(b)  If  the  rupture  is  complete  and  the  two  ends  are  widely 
separated,  the  difficulties  are  aggravated.  There  is  no  trace  of  the 
upper  wall  left  to  assist  in  the  slightest  degree  in  locating  the  orifice 
of  the  proximal  segment  of  the  urethra. 

"With  the  point  of  the  grooved  director,  every  small  orifice,  every 


Fig.  525. — Soft  catheter  passed  into  the  bladder  after  repair  of   the  upper   wall.     (Duval.) 


depression,  every  fringed  tubercle  must  be  examined  in  the  hope  that 
it  represents  the  opening." 

If  you  find  something  which  looks  like  mucosa  and  the  lumen  of 
the  canal,  introduce  the  point  of  your  catheter  and  if  it  is  in  the  right 
track,  it  will  glide  into  the  bladder. 

"A  good  light,  patience,  perseverance,  and  an  accurate  knowledge 
of  the  anatomical  relations  of  the  injured  parts  often  lead  to  success 
in  the  most  difficult  cases."     (Senn's  Practical  Surgery.) 


694 


RUPTURE    OF   THE   URETHRA 


Pressure  on  the  bladder  may  sometimes  help  by  forcing  a  drop  or 
two  of  urine  through  and  thus  exposing  the  urethral  opening.  Some- 
times bleeding  from  the  ruptured  artery  of  the  bulb  will  serve  as  a 
guide  to  the  hidden  opening. 

The  incision  may  be  extended  backward  with  a  view  to  exposing 
the  canal,  but  this  is  often  unsatisfactory  and  care  must  be  taken  not 
to  wound  the  anal  sphincter. 

If,  by  any  of  these  means,  the  orifice  is  finally  located  and  the 
catheter  passed  into  the  bladder,  it  remains  to  adjust  and  suture  the 


Fig.  526. — Repair  of  the  musctilar  layers.     (Duval.) 

divided  ends.  The  ideal  way  consists  in  making  an  end-to-end 
anastomosis,  passing  the  sutures  through  the  outer  coats  only. 
Occasionally  you  will  be  satisfied  if,  by  passing  sutures  through  all 
the  coats,  you  can  approximate,  in  some  degree,  the  two  ends,  favor- 
ing by  that  much  the  ultimate  restoration  of  the  canal  and  minimiz- 
ing the  stricture  formation  (Fig.  525). 

*'In  twenty-nine  reported  cases  of  rupture  of  the  urethra  treated 
by  immediate  suture,  all  are  announced  as  successful.  These  results 
are  astonishing  and  commend  repetition."  (Bryant's  Operative 
Surgery.) 


SUPRAPUBIC   CYSTOTOMY  695 

After  suture  of  the  urethral  tear,  the  perineal  wound  may  be  short- 
ened a  little  by  one  or  two  sutures,  but  ample  space  must  be  left  for 
drainage.  A  wound  unnecessarily  large  is  much  less  dangerous  than 
one  too  small  (Fig.  526). 

Pack  the  wound  with  iodoform  gauze.  The  catheter  should  be 
left  in  the  bladder  for  three  to  four  days,  when  it  is  removed  and  a 
steel  sound  passed  thereafter  every  two  or  three  days  until  repair  is 
complete. 

(c)  What  are  you  to  do  in  case  patient  search  fails  to  locate  the 
bladder  end  of  the  torn  canal  and  you  are  unable,  therefore,  to  pass 
the  catheter  into  the  bladder  and  to  suture?  Two  procedures  are 
recommended: 

(i)  Pack  the  wound  with  iodoform  gauze  and  empty  the  bladder 
as  necessary  by  suprapubic  puncture.  Perhaps  at  a  later  examina- 
tion the  opening  may  be  found,  or,  as  will  nearly  always  happen,  the 
bladder  is  sufficiently  drained  after  a  day  or  two,  through  the  perineal 
wound. 

(2)  Do  a  suprapubic  cystotomy  and  "retrograde  catheterization." 
Where  the  general  condition  of  the  patient  and  other  circumstances 
permit,  this  procedure  is  the  better,  since  it  assures  drainage 
and  facilitates  primary  repair  by  definitely  locating  the  bladder 
end  of  the  torn  urethra  in  the  perineal  wound.  It  is  necessarily 
a  dehcate  operation  and  should  not  be  undertaken  by  the  wholly 
inexperienced. 

To  perform  suprapubic  cystotomy  and  retrograde  catheterization, 
begin  by  carefully  disinfecting  the  abdominal  wall.  Make  an  in- 
cision 2}^  inches  long  in  the  middle  line,  beginning  at  the  pubes 
and  cutting  through  the  skin  and  subcutaneous  tissues  and  the 
fascias.  Retract  the  lips  of  the  wound  widely.  You  may  not  be 
able  to  distinguish  the  peritoneal  covering  of  the  bladder,  for  it  may 
be  above  the  upper  level  of  the  wound.  In  any  event,  it  must  be 
pushed  up  out  of  the  way.  Next  locate  the  bladder,  which  is  easily 
felt  if  it  is  distended;  but  if  it  is  not,  follow  the  posterior  surface  of 
the  pubes. 

Transfix  the  anterior  wall  by  a  suture  on  each  side  of  the  proposed 
line  of  incision,  and  lift  the  bladder  upward  to  the  abdominal  wound 
and  open  it  by  a  free  incision.     A  small  incision  is  a  nuisance,  while 


696  RUPTURE  or  THE  URETHRA 

a  large  incision  renders  the  subsequent  steps  easier  and  is  easily 
sutured  at  the  end  of  the  operation. 

With  the  bladder  opened,  the  next  step  is  to  pass  the  catheter. 
If  possible  locate  the  urethral  orifice  in  the  bladder  and  pass  the 
catheter  by  sight,  but  you  will  usually  have  to  depend  upon  touch 
for  this  procedure. 

Introduce  the  left  index  and  middle  fingers  into  the  bladder  and 
touch  the  base.  Now  draw  the  fingers  forward  in  the  middle  line 
and  the  neck  of  the  bladder  will  be  recognized  by  its  relation  to  the 
prostate,  and  the  urethral  opening  feels  like  a  pimple  on  the  base  of 
the  gland.  The  catheter  is  now  slipped  along  the  finger  resting  on 
the  orifice.  Once  engaged,  it  is  pushed  on  through  the  urethra  until 
its  point  emerges  in  the  perineal  wound.  Couple  it  onto  the  soft 
catheter  in  the  anterior  part  of  the  urethra  and  retract  it  through 
the  abdominal  wound,  and  by  this  means  the  catheter  in  front  is 
drawn  into  place  and  should  be  left  in  the  bladder  after  the  urethra 
and  perineal  wounds  are  sutured,  as  before  described. 

We  must  now  provide  for  the  drainage  of  the  bladder  through 
the  suprapubic  wound.  Employ  a  medium-sized  catheter  and  let  it 
reach  almost  to  the  bottom  of  the  bladder  and  anchor  it  in  place 
with  a  safety-pin.  Suture  the  bladder  wound  tightly  about  the 
tube.  Repair  the  abdominal  wall,  leaving  enough  room  for  light 
gauze  packing  about  the  tube. 

"Many  elaborate  methods  of  suprapubic  drainage  are  described, 
but  this  tube  connected  to  a  long  rubber  tube  by  means  of  a  glass 
coupler  and  terminating  beneath  the  bed  in  a  bottle  filled  one-quarter 
full  of  bichloride  solution,  will  meet  all  the  requirements  of  the  case." 
(Taylor,  G.  U.  and  Venereal  Disease.) 

The  tube  may  be  replaced  by  a  smaller  one  after  two  or  three  days. 
As  soon  as  possible,  the  wound  is  allowed  to  fill  up  by  granulation 
and  the  drain  is  entirely  removed. 

RUPTURE  OF  THE  MEMBRANOUS  URETHRA 

This  accident  is  rare  except  in  connection  with  fractures  of  the 
pelvis.  Under  any  circumstances,  it  is  even  more  dangerous  than 
rupture  in  front  of  the  triangular  ligament,  for  the  extravasated 


RUPTURE  OF  THE  PENDULOUS  URETHRA  697 

urine  may  easily  spread  up  into  the  pelvic  cavity  and  induce  cellulitis 
and  general  infection.  Examination  per  rectum  will  often  reveal  the 
edema,  no  signs  of  which  appear  in  the  perineum. 

Nothing  but  free  incision  and  drainage  through  the  perineum  is 
of  any  use. 

f^inally  the  pendulous  portion  of  the  urethra  may  be  ruptured, 
sometimes  in  coitus,  and  the  hemorrhage  may  be  quite  alarming  to 
the  patient;  there  may  also  be  retention  of  urine.  Usually  catheteri- 
zation will  be  sufficient. 


CHAPTER  XX 

ACUTE  RETENTION,  CATHETERIZATION,  SUPRAPUBIC 
PUNCTURE,  CYSTOTOMY,  URINARY  INFILTRATION 

Every  acute  retention  of  urine  demands  immediate  relief.  It 
must  be  relieved  not  only  on  account  of  pain  and  discomfort,  but 
more  especially  to  avoid  damage  to  the  bladder  or  urethra  and  the 
evil  effects  of  sepsis.  This  rule  applies  equally  to  the  cases  due  to 
temporary  insufficiency  of  the  bladder  musculature  and  to  those  due 
to  urethral  obstructions. 

Urethral  obstruction  may  assume  various  forms.  In  general  prac- 
tice, it  will  usually  originate  in  one  of  three  ways:  spasm  of  the  ure- 
thra, enlargement  of  the  prostate  gland,  or  stricture.  Very  many 
more  times  than  we  suspect  in  those  cases  regarded  as  simple  reten- 
tion from  spasm,  the  real  and  predisposing  cause  is  organic.  In  every 
case  before  instituting  measures  for  relief,  it  is  wise  to  make  minute 
inquiry  into  the  patient's  history  with  respect  to  this  function.  At 
least  one  should  be  suspicious  of  the  presence  of  stricture  and  on  his 
guard. 

It  is  true  that,  in  a  particular  case,  certain  circumstances  tend  to 
make  one  or  the  other  of  the  causes  of  retention  the  more  probable. 
Thus,  if  the  patient  is  in  a  febrile  attack  or  has  suffered  some  slight 
trauma  of  the  urethra  or  has  undergone  an  operation  on  a  region  ad- 
joining the  urinar}'  tract,  one  thinks  of  retention  from  urethral  spasm. 
If  the  patient  is  known  to  have  a  sexual  history,  has  been  a  votary  at 
the  shrine  of  Bacchus  and  Venus,  the  logical  inference  is  organic  stric- 
ture. If  the  afflicted  one  is  elderly,  one  thinks  of  enlarged  prostate, 
though  mere  age  does  not  rule  out  other  causes  of  obstruction.  One 
may  be  past  the  hey-day  of  life  and  yet  strictured,  paying  late  the 
price  of  pleasures  long  since  fled. 

But  after  all,  whether  the  predisposing  cause  is  temporary  or  per- 
manent, the  actual  exciting  cause  is  usually  congestion.     This  is  a 

698 


ACUTE   RETENTION 


699 


practical  point  constantly  to  be  borne  in  mind,  for  it  is  congestion 
which  makes  urethral  instrumentation  potent  to  produce  trouble,  and 
which  makes  strict  asepsis  an  absolute  necessity. 

CATHETERIZATION 

The  first  measure  of  relief  to  be  tried  in  actual  retention,  if  opium 
and  a  prolonged  warm  bath  are  not  practical,  is  catheterization.  To 
meet  the  possible  indications  every  practitioner  should  be  armed. 
A  certain  equipment  is  indispensable. 

A  cylindrical  metal  case  capped  at  one  end  is  most  convenient  in 
which  to  keep  and  carry  these  instruments.     The  most  essential  are 


Fig.  527. — Corneal. 


Fig.  528. — Olivary. 

Fig.  529. — Cylindrical. 
{Stewart.) 


Fig.  530. — Elbowed  flexible  catheter. 


Fig.  531. — Mercier  double  elbowed  flexible  catheter. 

soft-rubber  catheters  of  various  sizes,  flexible  bougies  with  olivary 
and  conical  tips,  gum  catheters  with  single  and  double  elbows  or 
armed  with  stylets,  filiform  bougies  (Figs.  527,  528,  529,  530,  531). 

Sterilization  of  these  instruments  may  be  a  problem,  except  as  to 
the  rubber  catheters,  which  may  without  injury  be  disinfected  by 
boiling.  The  other  instruments  are  best  sterilized  by  formaldehyde 
vapor  and  should  be  prepared  before  leaving  the  office  and  carried 
wrapped  in  sterile  cloths. 

Without  the  special  sterilizer,  one  must  boil  these  instruments, 
risking  eventual  injury.  They  may  be  fairly  well  cleaned  by  rubbing 
with  an  antiseptic  ointment  or  by  immersion  in  a  1-20  carbolic  or 


yoo  CATHETERIZATION 

i-iooo  bichloride  solution.  Previous  to  its  introduction,  anoint  the 
catheter  with  sterile  vaseline  or  similar  lubricant. 

Position  of  Patient. — The  patient  should  lie  upon  a  table  high 
enough  that  the  operator  does  not  need  to  stoop.  The  pelvis  should 
be  elevated  and  the  thighs  flexed  and  abducted.  Begin  by  thor- 
oughly cleansing  the  field;  cleanse  the  penis,  the  foreskin  on  both  sides, 
the  glans  and  the  meatus,  wiping  each  part  with  a  separate  com- 
press. If  possible,  irrigate  the  urethra  with  boric  acid  or  normal  salt 
solution. 

Whatever  condition  may  be  suspected  in  an  unexplored  urethra, 
make  the  first  attempt  at  relief  wdth  a  large  catheter,  seventeen  or 
eighteen  French,  which,  as  is  well  known,  excites  less  resistance  than 
one  of  smaller  size.  Standing  at  the  patient's  left  side,  hold  the  penis 
between  the  finger  and  thumb  of  the  left  hand,  elongating  it,  while 
managing  the  catheter  with  the  right.  Usually  it  is  best  to  hold  the 
instrument  parallel  with  the  groin  as  its  beak  enters  the  meatus, 
gradually  bringing  the  handle  to  the  middle  line  of  the  abdomen  as 
the  instrument  penetrates.  As  the  catheter  progresses  it  may  be 
helped  along  by  giving  it  a  slightly  boring  motion.  Proceeding  thus 
gently  but  steadily,  always  avoiding  force,  the  bladder  may  be 
reached.  If  not,  a  smaller  catheter  is  to  be  tried,  and  so  on  until  one 
is  found  that  will  enter.  If  all  these  efforts  fail  and  it  becomes 
evident  that  a  practically  i?n permeable  stricture  is  present,  resort  must 
be  had  to  filiform  bougies,  which  may  be  bent  into  various  shapes, 
bayonet  shape,  or  corkscrew  form,  and  kept  so  by  a  thick  collodion 
coating. 

A  filiform  bougie  is  passed  until  it  engages,  and  then  various  back 
and  forth,  side  to  side,  movements  are  imparted  with  the  hope  of 
finding  a  passageway  through  the  scar  tissue.  The  point  may  en- 
gage in  lucunae  or  in  false  passages,  and  often  it  is  useful  to  leave  the 
bougie  in  situ.  A  half-dozen  may  be  left  in  the  urethra  to  occupy 
the  false  passages,  until  happily  one  finally  passes  into  the  urethral 
canal.  Once  a  bougie  is  introduced  into  the  bladder,  it  should  be 
fastened  and  left  until  the  second  day,  when  often  it  may  be  replaced 
by  a  soft  catheter  or  a  larger  bougie.  In  the  meantime,  the  urine 
trickles  past  the  stricture  drop  by  drop,  until,  in  a  short  time,  the 
distention  is  relieved. 


CATHETERIZATION 


•Ol 


If  the  retention  is  known  from  the  first  to  be  due  to  stricture,  the 
procedure  may  vary  somewhat.  Valentine  and  Townsend  have 
defined  the  technic  of  emergency  dilatation  of  urethral  stricture 
in  such  a  satisfactory  manner  (American  Journal  of  Surgery,  May, 
1907)  that  it  is  transposed  for  present  use  practically  in  its  entirety. 

The  hyperesthesia  of  the  urethra,  often  so  great  an  obstacle  in 


Fig.   532. — Lubricating  the  urethra.      (American   Journal  of  Surgery.) 


catheterization,  is  greatly  relieved  by  filling  the  urethra  with  a 
2,s  per  cent,  solution  of  malaleuca  sempervirens  in  sterile  oil  and 
holding  it  for  three  to  five  minutes.  Local  or  general  anesthesia  is 
undesirable. 

No  lubricant  is  used  for  filiforms,  but  the  urethra  is  to  be  lilled 
with  10  per  cent,  suspension  of  iodoform  in  glycerin,  injecting  with  a 
sterile  glass  syringe  of  i-ounce  capacity.     The  penis  is  held  in  the 


702  CATHETERIZATION 

left  hand,  the  index  finger  and  thumb  pressing  the  meatus  open. 
The  tip  of  the  syringe  is  inserted  and  the  contents  slowly  injected 
until  it  can  be  felt  that  the  urethra  is  full  (Fig.  532).  When  the  in- 
jection is  complete  the  finger  and  thumb  compress  the  meatus  to 
prevent  the  escape  of  any  of  the  fluid  to  make  the  fingers  or  penis 
slippery. 

The  filiform  is  to  be  inserted.     A  straight  bougie,  5  French,  is  in- 


FiG.  533. — Inserting  a  filiform.     {American  Journal  oj  Surgery.) 

serted  as  far  as  it  will  go  without  force  (Fig.  533).  A  smaller  one  is 
then  passed  alongside  the  first  and  the  procedure  continued  with 
smaller  straight  bougies  until  a  No.  i  has  been  inserted  as  far  as 
possible.  This  is  then  left  in  place  and  from  three  to  six  more  intro- 
duced, each  one  being  left  at  the  point  of  arrest. 

When  as  many  filiforms  as  will  pass  the  meatus  without  stretching 
it  are  thus  inserted,  the  one  first  introduced  may  be  urged  slightly  for- 
ward.    If  its  point  is  free  but  cannot  progress,  it  may  be  withdrawn 


CATHETERIZATION 


703 


and  an  angular  filiform  inserted  in  its  place.  It  should  be  gently- 
rotated  to  the  right  and  left  as  obstruction  is  met  with.  If  it  makes 
no  progress,  it  may  be  left  in  place  and  another  of  the  straight  fili- 
f orms  withdrawn  to  be  replaced  by  a  bayonet  filiform.  The  bayonet 
filiform  is  to  be  pressed  forward  and  then  withdrawn  slightly  and 
again  advanced  in  a  different  direction,  hoping  to  find  the  lumen.  If 
this  fails,  the  corkscrew  filiform  is  to  be  tried,  removing  some  of  the 
straight  filiforms  if  necessary  to  have  more  room. 


i^ 


Fig.  534. — KoUmann  filiform  guides.     (American  Journal  of  Surgery.) 

When  the  corkscrew's  tip  reaches  the  face  of  the  stricture,  it  is  to 
be  rotated,  trying  first  the  right  spiral  and  then  the  left.  If  the  sec- 
ond one  fails,  leave  it  in  place  and  try  each  of  the  straight  ones  again, 
pushing  it  gently  forward,  and  if  it  fails  to  enter,  withdrawing  it. 
After  all  the  straight  ones  are  tested  and  removed,  try  the  corkscrew 
that  remains  in  the  urethra  and  then  the  one  tried  first. 

If  all  these  maneuvers  have  failed,  an  attempt  may  be  made  with 


Fig.  53  5. — Valentine-Townsend  filiform  carrier.     (American  Journal  of  Surgery.) 

the  Kollmann  guide  (Fig.  534).  A  straight  or  curved  guide  is  to  be 
used,  depending  upon  the  location  of  the  stricture.  It  is  passed  up 
to,  and  pressed  firmly  against  the  face  of  the  stricture,  while  a  straight 
filiform  is  introduced  and  lightly  pushed  up  against  the  stricture, 
changing  the  position  of  the  guide  from  time  to  time.  If  this  attempt 
with  the  Kollmann  guide  fails,  a  metal  sound  as  large  as  will  pass  to 
the  stricture  by  its  own  weight  is  introduced  and  held  against  the 


704 


CATHE  TERIZATION 


stricture  for  live  minutes  or  more  and  quickly  withdrawn  and  the 
urethra  relilied  with  the  iodoform-glycerin  solution  and  all  the  ma- 
neuvers with  the  filiforms  repeated,  often  with  the  result  that  the 
first  inserted  will  traverse  the  stricture  and  enter  the  bladder  smoothly. 
The  urethroscope  is  sometimes  useful  in  locating  the  orifice,  but 
even  then  the  filiform  may  be  difficult  to  enter,  manifesting  the 
"perversity  of  things  inanimate;"  although  the  shortest  urethroscope 

tube  be  used,  the  filiform  will  cling  to  its 
sides  or  will  sway  to  and  fro,  touching 
every  point  of  the  exposed  region  except 
the  orifice.  Under  the  circumstances, 
the  Valentine-Townsend  filiform  carrier 
(Fig.  535)  is  to  be  recommended  and  its 
use  is  thus  described: 

After  the  urethroscopic  tube  is  inserted, 
the  urethral  mucosa  dried,  and  the  light 
in  place,  the  carrier,  armed  with  a  fili- 
form, is  inserted.  The  lowermost  ring 
containing  the  filiform's  tip  is  pressed 
against  the  face  of  the  stricture  at  the 
point  where  its  lumen  is  visible.  Once 
fixed  by  slight  pressure,  the  filiform  is 
very  slowly  projected  into  the  exposed 
lumen.  If  it  fails  to  traverse  the  stric- 
ture, an  angular  and  then  a  corkscrew 
filiform  are  tried  as  before  described. 

Whenever  a  filiform  reaches  the  bladder, 
the  fact  is  announced  by  the  ease  with 
which  the  instrument  can  be  moved  to 
and  fro,  and  by  the  increased  desire  to  urinate  when  the  filiform 
touches  the  bladder  walls.  A  few  drops  of  urine  trickle  by  the  filiform . 
The  filiform  must  he  fastened  in  place:  No  effort  must  be  made  at 
this  time  to  pass  a  larger  instrument.  Valentine  and  Townsend 
recommend  the  following  method  of  holding  the  filiform  in  place: 

Two  pieces  of  sterile  cord  6  inches  long  are  used,  one  tied  about 
the  bougie  in  front  of  the  meatus  so  that  the  knot  corresponds  to  the 
dorsum  of  the  penis,  and  the  other  tied  so  that  the  knot  corresponds 


Fig.  536. — Cord  attached  to 
instrument  in  urethra.  (.4  merican 
Journal  of  Surgery.) 


CATHETERIZATION 


705 


to  the  insertion  of  the  frcnum  (Fig.  536).  ''Take  the  cords  project- 
ing from  one  side  of  the  glans  and  pass  them  through  one  of  the  four 
holes  of  a  common  pearl  shirt  button,  draw  the  button  upon  the  two 
joined  cords  until  it  rests  exactly  at  the  post,  coronary  sulcus.  Tie 
a  knot  in  each  cord  at  that  point  to  fasten  the  button  in  place"  (Fig. 
537).     Proceed  in  the  same  manner  on  the  opposite  side. 


Fig.  537. — Attaching  button  to  cord.     (American  Journal  of  Surgery.) 


A  cord  passing  over  the  penis  connects  the  two  buttons;  another 
passing  under  the  penis  is  threaded  onto  the  two  buttons  and  tied, 
care  being  taken  not  to  disturb  the  position  of  the  two  buttons  (Fig. 
538).  Finally  a  cord  12  inches  long  is  fastened  into  the  remain- 
ing hole  of  each  button,  and  carried  backward  to  be  attached  to  the 
pubic  hairs  after  Guyon's  method  (Fig.  539). 


Fig.  538. — Uniting  cords  attached  to  button,  lateral  holes.      (American  Journal  of  Surgery.) 

"The  penis  is  then  to  be  dressed,  covering  it  with  an  aseptic  gar- 
ment. 

''Three  lavers  of  sterile  gauze  10  inches  square  are  folded  to  form 
a  triangle.  This  is  passed  under  the  penis  with  the  base  toward  the 
scrotal  angle.  The  apex  is  tied  to  the  instrument  at  its  projection 
45 


7o6 


CATHETERIZATION 


from  the  meatus.  The  two  angles  at  the  base  are  carried  in  front  of 
the  penis,  one  above  the  other,  and  their  points  are  attached  to  the 
pubic  hairs  by  the  extremities  of  the  cords  left  after  tying  in  the 
instrument"  (Fig.  540). 

A  pad  of  cotton  should  cover  the  genitals,  and  the  whole  be  covered 
by  a  towel,  to  be  changed  as  often  as  soiled. 

''While  it  is  better  that  the  patient  with  a  filiform  fixed  in  his 


CJjff-iM 


Fig.  539. — Cords    attached   to    pubic    hairs. 
{American  Journal  of  Surgery.) 


Fig.  540. — Penis  dressed.     {American 
Journal  of  Surgery.) 


bladder  remains  in  bed,  there  are  circumstances  in  which  it  is  impera- 
tive that  he  be  allowed  to  go  about  and  attend  to  his  occupation. 
Protected  against  the  dangers  of  retention  as  above,  this  is  permissi- 
ble unless  he  be  engaged  at  hard  labor." 

In  the  case  of  retention  due  to  enlarged  prostate,  the  mode  of  proced- 
ure is  quite  different  if  the  primary  effort  at  passing  a  soft  catheter 
fails. 


SUPRAPtTBIC   PUNCTURE  707 

The  prostatic  catheter  with  long  curve  may  be  tried,  passing  it  as 
deeply  as  possible  before  depressing  the  handle  between  the  thighs, 
pulling  the  penis  upward,  elongating  it  to  facilitate  the  movement  of 
the  sound.  Once  the  point  is  in  the  perineal  region,  the  handle  is  to 
be  depressed  rapidly,  at  the  same  time  pushing  the  sound  on,  hoping 
in  this  manner  to  carry  it  over  the  prostatic  projection.  No  force 
must  be  employed.  Often  the  Mercier  elbowed  or  double-elbowed 
catheter  will  surmount  the  difficulty  (see  Figs.  453  and  454). 

Sometimes  a  large  gum  elastic  catheter  armed  with  a  stylet  may  be 
useful.  The  catheter  is  introduced  to  the  obstruction,  the  stylet 
slightly  withdrawn,  which  serves  to  tilt  the  end  of  the  catheter  and 
permits  it  to  be  pushed  on  into  the  bladder. 

In  these  cases  of  chronic  enlargement  of  the  prostrate,  frequent 
catheterization  may  be  required.  As  Stewart  (Surgery,  page  653) 
says,  if  it  becomes  difficult,  if  there  is  marked  irritability  of  the 
bladder,  if  the  residual  urine  steadily  increases  in  quantity,  or  if 
there  is  stone  or  persistent  cystitis,  catheterization  must  be  aban- 
doned and  operation  advised. 

PUNCTURE  OF  THE  BLADDER 

When  catheterization  has  failed  and  relief  is  imperative,  supra- 
pubic puncture  is  the  next  resort.  It  is  in  nowise  dangerous  if  aseptic, 
except  possibly  in  those  long  strictured  or  long  troubled  with  enlarged 
prostate,  when  the  peritoneal  covering  of  the  bladder  may  approach 
the  pubes. 

Begin  with  a  careful  disinfection.  Shave  and  scrub  the  abdomen 
and  pubes.  Select  for  puncture  the  point  immediately  above  the 
pubes  in  the  middle  line  exactly.  The  instrument,  which  may  be  an 
aspirator  or  simply  a  trocar,  is  to  be  entered  at  the  point  indicated, 
without  fear  of  going  too  deep,  and  pushed  backward  and  slightly 
downward  until  resistance  ceases.  Withdraw  the  stylet  and  the 
urine  follows  in  a  steady  stream.  A  rubber  tube  may  be  attached 
to  the  trocar.  The  bladder  should  not  be  emptied  rapidly,  but 
slowly,  interrupting  the  flow  from  time  to  time.  When  the  bladder 
is  emptied,  the  trocar  is  to  be  withdrawn  wdth  a  rapid  movement 


7o8  CYSTOTOMY 

and  the  opening  covered  with  a  sterile  compress,  or,  if  quite  small, 
with  collodion. 

Aseptic  puncture  may  be  practised  once  or  twice  a  day  for  a  num- 
ber of  days  without  serious  consequences,  and  at  the  end  of  this  time 
the  congestion  of  the  urethra  may  be  relieved  and  the  urinary  func- 
tion restored.  If,  however,  at  this  time  the  urethral  obstruction 
cannot  be  overcome,  then  one  must  proceed  to  establish  permanent 
drainage. 

Permanent  drainage  is  indicated  from  the  first  if  distance  precludes 
two  or  three  daily  visits,  for  there  is  no  use  to  relieve  the  patient  by 
puncture  and  then  leave  him  to  the  danger  and  pain  of  a  new  re- 
tention, certain  to  occur. 

Again,  if  the  urethra  has  been  lacerated  by  rough  attempts  at 
catheterization,  and  if  to  the  symptoms  of  retention  are  added  those 
of  sepsis  and  the  signs  of  beginning  infiltration,  it  is  imperative  to 
establish  permanent  drainage  of  the  bladder. 

Under  these  circumstances  the  puncture  may  be  performed  with  a 
large  trocar,  and  after  the  bladder  is  emptied  a  catheter  can  be  passed 
through  the  cannula  into  the  bladder  as  far  as  possible  and  the  can- 
nula gently  withdrawn. 

The  catheter  must  be  fixed  in  position,  and  this  can  readily  be  done 
by  threads  attached  to  the  skin  with  collodion.  To  the  catheter  a 
long  rubber  tube  should  be  attached,  ending  below  in  a  vessel  con- 
taining an  antiseptic  solution.  By  this  means  a  siphonage  is  estab- 
lished and  the  bladder  kept  constantly  emptied  and  prevesical  in- 
filtration avoided. 

CYSTOTOMY 

Permanent  drainage  through  the  suprapubic  puncture  is  often 
alone  available,  though  by  no  means  ideal.  Whenever  possible,  the 
bladder  is  to  be  opened  formally  and  the  drainage  established  by 
that  means,  nor  is  the  operation  beyond  the  skill  of  the  general 
practitioner. 

No  special  equipment  is  necessary:  scalpel,  scissors,  artery  forceps, 
dissecting  forceps,  small  curved  needles.  Local  anesthesia  may  be 
employed  in  case  of  necessity,  though,  of  course,  general  anesthesia 
is  desirable.     The  region  is  to  be  carefully  prepared. 


CYSTOTOMY 


709 


Operation. — Begin  with  an  incision  3  inches  long  commencing 
at  the  pubes  and  extending  upward  in  the  middle  line  (Fig.  541). 
Divide  the  skin  and  fat  down  to  the  aponeurosis.  Divide  the  aponeu- 
rosis and  expose  the  prevesical  fat  (Figs.  542-543).  Draw  this  fatty 
tissue  upward,  and  with  it  the  vesical  peritoneum,  exposing  the  blad- 
der.    The  bladder  appears  dark  and  globular,  marked  by  large  veins. 


A 

/aHi\ 

r^w!j\ 

I          T 

¥ 

I  ^ 

/ 

\i 

\il 

y  c^./f: 

Fig.   541. — Cystotomy.     Primary   incision   exposing   linea   alba. 


In  fat  subjects  it  may  seem  deeply  situated  in  spite  of  its  distention, 
but  one  need  nor  fear  to  get  into  something  else. 

It  is  helpful  in  controlling  the  bladder  and,  later  on  in  suturing, 
next  to  pass  a  suture  on  either  side  of  the  proposed  line  of  incision, 
The  sutures  should  pass  through  only  the  superficial  tissues  and  be 
parallel  to  the  bladder  incision.     Next  proceed  to  open  the  bladder 


lO 


CYSTOTOMY 


in  the  middle  line,  making  the  puncture  at  the  level  of  the  pubes  with 
the  cutting  edge  of  the  bistoury  turned  upward,  prolonging  the  in- 
cision from  a  half-inch  to  an  inch.  If  the  sutures  have  not  been 
passed,  catch  up  the  edges  of  the  vesical  wound  with  forceps  w^hile 
the  urine  flows  out. 


r                  ■■■■  ■ ■  ■    ■ 

^ 

^^mji^ 

V 

uH// 

W 

1. 

Fig.   542. — Partial  incision  of  the  deep  layer  of  the  sheath  of  the  recti,  exposing 

the  prevesical  fat. 


The  bleeding,  often  considerable  at  first,  is  not  a  matter  for  con- 
cern and  ceases  spontaneously  as  the  emptied  bladder  contracts. 

When  the  bladder  is  emptied,  douche  it  thoroughly  with  warm 
sterile  water  and  explore  its  cavity  for  possible  calculi. 

It  remains  to  suture  the  edges  of  the  bladder  wound  to  those  of 
the  skin  wound  (Fig.  544).  If  the  traction  sutures  mentioned  were 
passed,  they  may  now  be  used  to  draw  the  bladder  up  into  close  con- 


UPERATIVE    TECHNIC 


711 


tact  with  the  abdominal  wall,  passing  thcni  through  the  entire  thick- 
ness, and  tying  them  on  the  outside. 

The  mucous  membrane  is  now  brought  in  contact  with  the  skin 
and  sutured  with  catgut  (Fig.  545).  It  the  condition  of  the  vesical 
walls  does  not  permit  the  careful  coaptation  described,  then  four  or 
five  sutures  may  be  employed,  passing  through  all  the  layers  of  the 


/;^Pi\ 

1      -    iBw"'«k    i     \ 

i-m  Ik  A 

r^/n 

:_  Wft\.A\ 

I^H 

\.    '^    ' 

^/Km 

\     ' 

i/    (■■ 

,-/^i .    IMF  i 

• 

\ 

-rfP^^^ftf  y 

^^r. 

1  1 

<4t>. 

^^^s* 

«<*^^*r      }tk  f 

vtn- 

1^ 

^■*»,»^ 

^^^^ 

iaH 

1// 

^""^^^ 

V  A  ■I'll'-*: '  iBi  /. "-  / 

^^^Ic 

WwIiM/v 

v\lKKr/ 

Wm 

w 

\  ■ 

V 

Fig.  543. — Cystotomy.     Recti  separated,  prevesical  fat  exposed. 


bladder  and  abdominal  walls,  bringing  them  into  contact.  In  this 
case  a  catheter  must  be  introduced  and  siphonage  instituted.  In 
the  first  case,  where  the  skin  and  mucosa  are  exactly  coapted,  it  is 
not  necessary  to  leave  a  catheter  in  the  bladder.  The  skin  wound 
is,  of  course,  sutured  above  and  gauze  should  be  packed  around  the 
catheter.  The  after-history  will  depend  upon  the  condition  present, 
but  the  ultimate  aim  will  be  to  restore  the  urethral  functions. 


712 


INFILTRATION    OF   URINE 


INFILTRATION   OF   URINE 

Sometimes  it  happens  that  following  a  retention,  partial  or  com- 
plete, the  urethra  gives  way  and  the  urine  percolates  through  the 
adjoining  tissues.  Under  these  circumstances,  the  urine  is  nearly 
always  septic,  the  patient  debilitated,  and  the  conditions  are  thus  ripe 
for  a  rapid  fatality. 


\    ^1^ 

/ 

\ 

kji 

/ 

^ 

^1 

\ 

mTf 

^^^ 

^^"^^ 

--^^f^ 

-^^ 

^^ 

^ 

f 

1 

1 

Fig.   544. — Cystotomy.     Bladder  fixed  to  the  abdominal  wall,  sutures  passing  through  the 

recti;  bladder  opened. 


Shortly  after  the  rupture  of  the  urethral  wall,  the  perineal  tissues 
become  edematous,  and  the  scrotum  and  penis  markedly  swollen. 
The  infiltration  soon  involves  the  pubHc  and  hypogastric  region. 

The  symptoms  are  those  of  sepsis:  rigors,  fever,  pulse  rapid  and 
weak,  tongue  dry,  anxious  facies,  profound  depression  generally, 
the  symptoms  depending  in  degree  upon  the  duration  of  the  accident, 


OPERATIVE   TECHNIC 


713 


Fig.   545. — Cystotomy.     Suttires  connecting  the  edges  of  the  bladder  wound  and  the  skin. 

Repair  of  the  abdominal   wall. 


714 


INFILTRATION    OF    URINE 


the  rapidity  of  the  urine's  spread  and  its  septicity.  Diffuse  phleg- 
mon and  gangrene  may  rapidly  ensue. 

The  rupture  usually  occurs  in  front  of  the  triangular  ligament — 
the  deep  perineal  fascia — and  so  the  urine  moves  forward  toward 
the  scrotum  and  pubes,  which  is  the  direction  of  least  resistance 
(Fig.  546). 

The  treatment  has  two  ends  in  view:  to  relieve  the  burdened  tissues 


Fig.  546. — Rupture  of  the  urethra  in  front  of  the  deep  perineal  fascia  and  at  point  ot 
entrance  to  the  bulb;  showing  the  direction  which  the  infiltrating  urine  may  take  into  penis 
and  scrotum,  perineum,  and  suprapubic  region.      {Veau  after  Hartmann.) 


and  to  open  up  a  passage  to  the  point  of  rupture.  To  relieve  the 
engorged  tissues,  a  series  of  parallel  incisions  are  to  be  made,  extend- 
ing beyond  the  limits  of  apparent  infiltration,  for  the  deeper  tissues 
are  always  more  widely  involved  than  the  superficial.  The  incisions 
should  be  deep  enough  to  reach  the  deep  fascia.  The  bleeding  is  not 
likely  to  be  serious,  but  any  bleeding  points  may  be  caught  up,  and  if 
the  oozing  still  persists,  the  incisions  may  be  packed  with  iodoform 
gauze. 


OPERATIVE    TECHNIC  715 

To  expose  the  nrelhra,  i)ut  the  patient  in  the  Hthotomy  position 
and  make  an  incision  in  the  middle  line,  beginning  at  the  base  of  the 
scrotum  and  terminating  in  front  of  the  rectum  (Fig.  547).  There  is 
no  guide  but  the  middle  line,  for  the  tissues,  thickened  and  infiltrated, 
are  unrecognizable.  There  is  nothing  to  do  but  continue  to  cut, 
keeping  in  the  middle  tine,  until  rewarded  by  a  spurt  of  urine. 

All  the  incisions  are  to  be  thoroughly  irrigated  with  hot  normal 
salt  solution,  the  tissues  gently  squeezed  and  the  dead  tissues  re- 
moved. A  compress  saturated  with  peroxide  is  next  applied,  this 
covered  with  absorbent  cotton,  and  the  whole  retained  by  a  T- 
bandage. 


Fig.  547. — Infiltration  of  urine:     Perineal  incision.      {Veau.) 

Ordinarily  drainage  is  unnecessary,  for  the  open  wounds  give  free 
escape  to  the  fluids.  Often  one  is  surprised  at  the  completeness  of 
the  repair. 

At  first  the  urine  flows  out  through  the  breach  in  the  perineum, 
but  after  a  little  while  a  catheter  may  be  passed  and  fastened  in  the 
bladder  and  the  perineal  wound  allowed  to  heal. 

Lejars  prefers  the  thermo-cautery  to  the  bistoury,  both  because  the 
hemorrhage  is  less  and  because  it  exercises  a  salutary  action  upon  the 
tissues  about  to  become  gangrenous,  but  Veau  believes  the  knife  to 
be  better,  because  it  does  not  seal  the  mouths  of  interstitial  drains. 

If,  in  the  course  of  intervention,  an  abscess  cavity  extending  up 


7i6 


INFILTRATION    OF   URINE 


toward  the  pubes  is  found,  a  drainage-tube  must  be  passed  as  high  as 
possible  and  fastened  in  position  (Fig.  548). 

Sometimes  it  happens  that  the  urethral  rupture  occurs  behind  the 
perineal  fascia,  and  again  taking  the  direction  of  least  resistance,  the 
urine  may  pass  up  along  the  side  of  the  bladder  to  the  deep  layers  of 
the  abdominal  wall ;  or  it  may  pass  downward  and  backward  into  the 


Fig.   548. — Infiltration  of  urine;  placing  drain.      (Veau.) 


ischio-rectal  fossae.  This  condition  is  all  the  more  dangerous  for 
the  reason  that  the  external  manifestations  are  often  delayed  and  in 
consequence  the  true  condition  is  not  suspected  until  too  late. 

But  whenever  a  zone  of  infiltration  is  found,  wherever  it  may  be, 
incise  it  and  reach  the  urethra  if  possible.  In  the  intra-pelvic  in- 
filtrations it  may  be  necessary  to  open  and  drain  through  the  bladder. 


CHAPTER  XXI 
SUTURE  AND  LIGATION  OF  ARTERIES 

In  emergency  surgery  the  suture  of  a  divided  vessel  is  occasionally 
applicable,  but  the  doctor  will  usually  prefer  ligation,  which  will 
nearly  always  suffice. 

To  suture  a  vessel,  the  blood  current  must  be  under  temporary  con- 
trol by  means  of  a  clamp  protected  with  rubber,  that  the  tunica  in- 
terna may  not  be  injured. 

The  vessel  wall  is  seized  with  a  fine  forceps.  The  silk  sutures  are 
placed  one-sixteenth  of  an  inch  apart  in  a  longitudinal  wound,  and 
only  the  outer  coats  are  pierced. 

If  an  end-to-end  anastomosis  is  required,  three  sutures  are  recom- 
mended by  Murphy  and  the  proximal  end  is  invaginated  in  the  distal, 
the  sutures  being  passed  first  through  the  proximal  and  finally  through 
the  distal  end  from  within  outward  and  tied. 

The  indications  for  arterial  suture  are  as  follows: 

1.  Where  ligation  might  bring  about  serious  nutritional  change. 

2.  In  all  wounds  of  large  vessels. 

3.  Operative  wounds  where  a  part  of  the  vessel  must  be  sacrificed. 

LIGATION  OF  ARTERIES 

It  is  a  rule  almost  without  exception  that  a  divided  artery  must  be 
exposed  and  both  ends  tied. 

Occasionally,  in  the  case  of  secondary  hemorrhage,  it  will  be  im- 
possible to  secure  the  artery  at  the  site  of  the  hemorrhage  and  liga- 
tion at  some  point  in  the  course  of  the  artery  above  the  lesion  will 
then  be  imperative.  So  that  though  only  rarely  to  be  used  in  emer- 
gency surgery,  yet  the  technic  of  special  ligations  should  be  kept  in 
mind. 

General  rides  for  all  ligations  may  be  formulated: 

I.  Put  the  patient  in  some  position  best  to  expose  the  artery  and  its 
landmarks. 

717 


7i8 


SUTURE    AND    LIGATION    OF   ARTERIES 


2.  Outline  the  course  of  the  vessel,  using  aniline  if  necessary. 

3.  Tie  the  vessel,  but  avoid  tying  near  the  origin  of  a  large  branch 
if  possible. 

4.  Let  the  middle  of  the  skin  incision  correspond  to  the  point  of 
ligation  and  let  its  length  depend  upon  the  depth  of  the  vessel. 

5.  Let  the  first  incision  include  the  skin  and  superficial  fascia;  the 
incision  in  each  succeeding  layer  should  be  the  same  length  as  the 
first. 

6.  Each  structure  must  be  identified  as  exposed. 


Fig.  549. — Ligation  of  an  artery.     A,  opening  the  sheath;  B,  passing  the  ligature;  C,  tying 

the  ligature.      (Moullin.) 

7.  The  sheath  of  the  vessel  is  to  be  recognized  by  its  position,  pul- 
sation, and  feel  to  the  examining  finger. 

8.  The  sheath  is  pinched  up  in  the  form  of  a  cone,  the  base  of 
which  is  incised  with  edge  of  the  scalpel  turned  away  from  the  vessel. 

9.  Through  this  small  opening  the  vessel  is  gently  detached  and 
the  aneurism  needle  passed,  beginning  usually  on  the  side  in  rela- 
tion with  the  vein  and  keeping  it  in  close  contact  with  the  artery 
(Fig.  549)- 

10.  After  the  needle  is  threaded  and  withdrawn,  be  assured  that 
no  other  structures  will  be  included  in  the  ligature. 


LIGATION,   COMMON   CAROTID 


719 


11.  Draw  the  knot  tightly  enough  to  occlude  the  lumen  of  the 
vessel,  but  not  tightly  enough  to  crush  the  inner  coat. 

12.  The  subsequent  treatment  is  that  of  an  ordinary  wound. 

THE  COMMON  CAROTID  (Fig.  550) 

The  line  oj  the  artery  corresponds  to  the  anterior  border  of  the  ster- 
no-mastoid. 


•mcni  ntrfe 

-Omo-hi/cid 
\   Tnascle 

CarcUd 
j.fgry 


Fig.   550. — Ligation  of  the  common  carotid  and  facial  arteries.     (Moullin.) 

The  incision  should  be  3  inches  long  in  this  line,  the  middle 
of  the  incision  corresponding  to  the  cricoid  cartilage.  Divide  the 
skin,  fascia,  platysma;  catch  the  bleeding  veins,  and  divide  the  deep 
fascia  along  the  sterno-mastoid,  exposing  the  sheath  upon  which  lies 
the  descendens  hypoglossi  and  the  omo-hyoid.  Just  above  the  omo- 
hyoid, open  the  sheath  from  the  inner  side  so  as  to  avoid  the  internal 
jugular.  Pass  the  needle  from  outside,  also  to  avoid  the  internal 
jugular. 


720  SUTUHE   AND   LIGATION    OF   ARTERIES 

EXTERNAL  CAROTID 

Line. — Continuation  of  the  common  carotid. 

Incision. — Erom  the  angle  of  the  jaw  to  the  thyroid  cartilage,  divid- 
ing the  skin,  fascia,  and  platysma.     Ligate  divided  veins. 

Divide  the  deep  fascia,  exposing  the  sterno-mastoid,  which  is  to  be 
retracted.  Locate  the  posterior  belly  of  the  digastric,  the  hypoglossal 
nerve,  and  the  tip  of  the  cornu  of  the  hyoid. 

Expose  the  artery  opposite  the  cornu;  pass  the  ligature  between  the 
superior  thyroid  and  the  lingual  arteries,  avoiding  the  decendens  hy- 
poglossi  and  the  superior  laryngeal  nerve  behind.  The  operation 
presupposes  patience  and  a  thorough  knowledge  of  the  anatomy. 
Through  this  same  incision  the  superior  thyroid,  the  Ungual,  the 
facial,  the  occipital,  and  the  ascending  pharyngeal  arteries  may  be  tied 
at  their  origin. 

LIXGU.AL  fBeneath  the  Hyoglossus) 

Position. — -Place  the  patient  on  his  back,  turn  the  head  to  the  oppo- 
site side  and  raise  the  chin  (Eig.  551). 

Ineision. — Curved,  its  center  just  over  the  greater  cornu  of  the 
hyoid,  extending  from  the  symphysis  of  the  chin  to  the  angle  of  the 
jaw.  Divide  the  skin,  superficial  fascia,  platysma  and  deep  fascia. 
Ligate  the  numerous  veins  which  may  be  divided.  Locate  the  lower 
border  of  the  submaxillary  gland  and  divide  its  fascia,  thus  exposing 
it,  and  lift  it  upward  out  of  the  way. 

Develop  the  mylo-hyoid;  also  the  two  bellies  of  the  digastric  and 
draw  them  down  firmly.  In  the  bottom  of  the  wound  is  the  hyo- 
glossus muscle.  Identify  the  hypoglossal  nerve  with  the  lingual  vein, 
which  cross  the  hyoglossus.  Incise  the  hyoglossus  below,  and  paral- 
lel with,  the  hypoglossal  nerve.  Incising  carefully,  the  artery  bulges 
into  the  wound.  Ligate  the  artery  on  the  proximal  side  of  the  dorsalis 
linguae. 

SUBCLAVIAN  (Third  Portion) 

Position. — -Place  the  patient  on  his  back  with  shoulders  raised, 
head  turned  to  opposite  side,  and  angle  of  shoulder  depressed 
(Fig.  551)- 


LIGATION,    THE   SUBCLAVIAN 


721 


Incision. — From  the  posterior  border  of  the  sterno-mastoid,  over 
the  clavicle,  to  the  anterior  border  of  the  trapezius,  drawing  the  skin 
down  first  to  prevent  wounding  the  external  jugular.  Relax  the 
skin.  The  incision  now  lies  H  inch  above  the  clavicle.  If  more 
room  is  needed,  partially  divide  the  trapezius  and  sterno-mastoid. 
Divide  the  deep  fascia  and  ligate  veins. 

If  the  transversalis  colli  or  the  suprascapular  arteries  present, 
draw  them  to  one  side. 


'3fy  o-hi/pld  7^.. 


Fig.  SSI. — Ligation  of  the  subclavian  and  lingual  arteries.     (Moullin.) 


Now  identify  the  scalenus  anticus  muscle — -a  very  important  step, 
as  it  is  the  guide  to  the  artery.  Follow  the  external  border  of  the 
muscle  down  to  the  first  rib  and  there  the  pulsations  of  the  artery 
will  be  felt. 

Identify  the  lowest  cord  of  the  brachial  plexus,  which,  as  well  as 
the  pleura  and  the  subclavian  vein,  must  be  avoided  in  passing  the 
ligature. 
46 


722 


SUTURE   AND   LIGATION    OF   ARTERIES 


THE  AXILLARY  (Third  Portion) 


Position. — -Patient  supine,  shoulders  raised,  arm  at  a  right  angle; 
operator  between  arm  and  body  (Fig.  552). 

Incision. — -Along  the  line  of  junction  of  the  middle  and  anterior 
third  of  the  floor  of  the  space. 

Divide  the  skin  and  fascia  and  expose  the  inner  border  of  the 
coraco-brachialis.  Draw  the  coraco-brachialis,  the  median  and  mus- 
culocutaneous nerves  outward,  the  ulnar  and  internal  cutaneous 
nerves  inward.     Avoid  the  basiHc  and  axillary  veins. 


r'^r^y/'a-trere^iaruf  m/acla- 


Fig.  552. — Ligation  of  the  axillary  artery.     (Moullin.) 

BRACHIAL  (In  the  Middle  of  Arm) 
(See  Operation  for  Exposure  of  Median  Nerve.) 

BRACHIAL  (Bend  of  Elbow) 
Position. — ^Limb  extended  and  abducted,  operator  outside  of  arm 

(Fig.  553)- 

Incision. — Follow  the  internal  border  of  the  bicipital  tendon,  the 
center  of  the  incision  corresponding  to  the  bend  of  the  elbow.  Divide 
the  skin  and  superficial  fascia.  Isolate  the  median  basilic  vein  and 
the  internal  cutaneous  nerve,  retracting  them  inward.  Next  divide 
the  deep  and  the  bicipital  fascia  and  beneath  this  latter  lies  the  artery 
with  its  venae  comites,  the  median  nerve  to  the  inner  side. 

Do  not  neglect  to  repair  the  bicipital  fascia. 


LIGATION,    THE    RADIAL 


^2^ 


RADL\L  (In  the  Upper  Third  of  Forearm) 

Position. — Hand  supine,  surgeon  to  outside  cutting  downward 
(on  the  right)  (Fig.  554). 

Incision. — -Along  the  inner  border  of  the  supinator  longus  for  3 
inches,  dividing  the  skin  and  superficial  fascia.  Divide  the  deep  fas- 
cia and  separate  the  supinator  longus  and  pronator  radii  teres.     The 

Tendinous  Ajioncuroais 
di  Tided 


Fig.  553- — Ligation  of  the  brachial  at  head  of  the  elbow;  the  median  basilic  vein  and  internal 
cutaneous  nerve  drawn  inward.     (Moullin.) 


Sufiinator  lonr^us 


Fig.  554, — Ligation  of  the  radial  artery.     In  the  floor  of  the  wound  is  the  pronator  radii 
teres.     The  nerve  lies  some  distance  to  the  radial  side.     {Moullin.) 

artery  lies  under  the  border  of  the  supinator  longus  with  the  nerve  to 
the  outer  side. 

RADIAL  (At  Wrist) 

Position. — ^The  position  is  the  same  as  before. 
Incision. — -The  incision  is  along  the  supinator  tendon.     Avoid  the 
radial  vein  and  the  superficialis  volae  artery.     Divide  the  deep  fascia 


724 


SUTURE   AND   LIGATION   OF   ARTERIES 


and  separate  the  tendons  of  the  supinator  longus  and  flexor,  carpii 
radialis  and  between  them  lies  the  artery  and  its  venae  comites. 

ULNAR  (At  Wrist) 
(See  Exposure  of  Ulnar  Nerve,  page  362.) 


2>t;e/tjfascca, 


ioarCcriU/S  ywuscle/   **^  ■[      ■■:0MW^'' 


2it:n/e 


Fig.  5SS. — Ligation  of  external  iliac  and  femoral  arteries.     (Moullin.) 

SUPERFICIAL  FEMORAL  (At  Apex  of  Scarpa's  Triangle) 

Position. — Thigh   slightly  flexed,   rotated   externally,   abducted; 
surgeon  to  outer  side  (Fig.  555). 


LIGATION,   THE   FEMORAL  725 

Incision. — Three  inches  long,  with  center  over  apex  of  triangle. 
Divide  the  skin  and  superficial  fascia.  Avoid  the  long  saphenous 
vein.  Divide  the  deep  fascia  and  draw  the  sartorius  outward;  the 
adductor  longus,  inward.  Avoid  the  internal  cutaneous  and  the  long 
saphenous  nerves.  The  vein  lies  to  the  inner  side  and  a  little  behind 
the  artery. 

FEMOR.\L  (In  Hunter's  Canal) 

Position. — -The  position  is  the  same  as  before. 

Incision. — -Three  inches  in  the  line  of  the  artery  in  the  middle 

third  of  the  thigh.     Divide  the  skin  and  superficial  fascia.  Avoid 

the  internal  cutaneous  nerve  and  the  long  saphenous  vein.  Divide 


Tibialis  anticus 


(diqitoruui 


Fig.   556. — Ligation  of  the  anterior  tibial  artery.     The   nerve  lies  to  the 
fibular  side.      (Moullin.) 

the  deep  fascia,  expose  the  sartorius  and  draw  it  inward.  Incise  the 
roof  of  the  canal,  but  do  not  wound  the  long  saphenous  nerve  which 
is  just  beneath.     Draw  it  inward  and  expose  the  sheath  of  the  vessels. 

ANTERIOR  TIBIAL  (Middle  Third) 

Position. — Thighs  extended,  leg  turned  inward  and  the  foot  ex- 
tended to  indicate  the  position  of  the  tibialis  anticus  muscle. 

Incision. — Four  or  five  inches  long  in  the  line  drawn  from  the  head 
of  the  fibula  to  the  middle  of  the  front  of  the  ankle-joint  (Fig.  556). 
Expose  the  fascia.  Divide  it  in  the  same  line.  By  the  sense  of  touch 
locate  the  septum  between  the  tibialis  anticus  and  extensor  longus 
digitorum.     Flex  the  foot  to  permit  the  separation  of  these  muscles, 


726 


SUTURE    AND   LIGATION    OF   ARTERIES 


and  follow  the  septum  down  to  the  artery.     The  nerve  is  to  the  front 
and  outer  side.     Pass  the  ligature  from  without  inward. 

ANTERIOR  TIBIAL  (Lower  Third) 

Position. — Same  as  above. 

Incision. — ^Locate  the  tendon  of  the  tibialis  anticus;  along  its  ex- 
ternal border  divide  the  skin  for  3  inches.  Find  the  septum 
between  the  tibialis  and  the  extensor  proprius  hallucis.     In  this 


Fig.   557. — Ligation    of    the    posterior    tibial    artery.     The    gastrocnemius    retracted;    the 

soleus  divided.     {MouUin.) 

space  lies  the  artery  with  the  nerve  to  the  front  and  outer  side.     Pass 
the  ligature  from  without  inward. 

DORSALIS  PEDIS 

Position. — -Patient  on  back  with  foot  extended  and  resting  on  heel. 

Incision. — Two  inches  long  beginning  at  the  middle  of  the  lower 
border  of  the  annular  ligament.  Expose  and  separate  the  tendons  of 
the  extensor  proprius  hallucis  and  extensor  longus  digitorum;  the 
artery  is  seen  lying  upon  the  tarsal  ligaments.  The  nerve  lies  to  the 
fibular  side.     Pass  the  ligature  from  without  inward. 

POSTERIOR  TIBIAL  (Middle  Third) 

Position. — -Patient  on  back;  leg  and  thigh  flexed;  thigh  rotated 
outward  so  that  leg  lies  on  its  outer  side  (Fig.  557). 


LIGATION,    POSTERIOR   TIIJIAL 


727 


Incision. — -Four  inches  long,  along  the  line  J4  inch  behind  the 
internal  border  of  the  tibia.  Expose  and  divide  the  deep  fascia. 
Expose  and  develop  the  inner  border  of  the  gastrocnemius;  retract 
and  thus  expose  the  soleus  attached  to  the  inner  border  of  the 
tibia.  Divide  the  soleus  vertically,  and  at  the  bottom  of  the 
wound  is  seen  the  yellow  fibrous  aponeurosis  which  covers  the  vesssel 
and  deeper  layer  of  muscles.  Divide  the  aponeurosis  about  i3^ 
inches  from  the  internal  border  of  the  tibia  and  expose  the  artery. 
Draw  the  nerve  to  the  outer  side  and  pass  the  ligature  from  without 
inward. 


Fig.  558. — Ligation  of  the  posterior  tibial  behind  the  ankle.     {Moidlin.) 

POSTERIOR  TIBIAL  (At  the  Ankle) 

Position. — Turn  the  foot  on  its  outer  surface  (Fig.  558). 

Incision. — Curved,  3  inches  long,  with  center  midway  between 
malleolus  and  the  inner  tuberosity  of  the  os  calcis.  Divide  the  fascia 
and  the  internal  annular  ligament  cautiously.  The  artery  is  just  be- 
neath the  ligament.  Separate  the  veins  and  pass  the  ligature  from 
without  inward. 


CHAPTER  XXII 
SOME  PRACTICAL  AMPUTATIONS 

The  primary  aim  of  an  amputation  is  to  conserve  the  Hfe  or  health 
of  the  patient;  the  secondary  aim  is  to  conserve,  as  much  as  possible, 
the  function  of  the  member.  The  first  requires  that  as  much  as 
necessary  be  removed;  the  second,  that  no  more  than  necessary  be 
removed.  The  good  surgeon  will  always  adjust  and  harmonize 
these  two  principles  and  they  will  determine  the  time  and  technic  of 
the  particular  operation. 

The  time  element  is  of  especial  concern  in  traumatism  and  gan- 
grene, for  if  the  operation  is  done  too  early,  too  much  may  be  re- 
moved in  one  case  and  too  little  in  the  other.  In  traumatism,  tissue 
that  at  first  sight  seemed  beyond  remedy  may  survive;  in  gangrene, 
tissue  that  seemed  viable  may  be  left,  only  to  necessitate  another 
dangerous  operation;  so  that  following  traumatism  it  is  better  not  to 
operate  until  the  limit  of  the  devitalized  tissue  has  been  definitely 
determined;  and  in  the  case  of  gangrene,  until  the  line  of  demarcation 
has  definitely  formed. 

The  techfiic  is  principally  concerned  with  conservation  of  function, 
and  looks  to  the  formation  of  a  good  stump.  "A  stump  to  be  service- 
able, should  be  sound,  unirritable,  with  good  circulation  and  abun- 
dant leverage"  (Bryant,  Operative  Surgery).  To  produce  a  stump 
with  these  qualities  requires  prevision  of  the  flaps,  particularly  their 
shape,  length,  and  vascularity.  Upon  their  shape  will  depend  the 
position  which  the  cicatrix  will  take;  upon  their  length,  the  com- 
fortable adjustment  of  skin  and  bone;  upon  their  vascularity,  the 
prompt  repair,  proper  nutrition,  and  subsequent  freedom  from 
disease. 

The  cicatrix  should  fall  where  it  will  be  least  subject  to  pressure 
and  friction  wherever  that  may  be  done  without  the  sacrifice  of  useful 
tissues.     In  determining  the  position  of  the  cicatrix,  one  must  then 

728 


GENERAL   TECHNIC  729 

consider  the  occupation  of  the  patient  and  the  possibiHty  of  an  arti- 
ficial limb  being  worn. 

In  the  case  of  the  leg,  for  example,  the  greatest  tension  might  fall 
on  the  end  of  the  stump,  and  a  scar  there  be  some  source  of  annoy- 
ance; in  the  case  of  an  arm,  more  pressure  might  fall  on  the  side,  from 
artificial  appliances,  and  an  end  scar  would  therefore  be  more  satis- 
factory. Nerves  likely  to  be  pinched  up  in  the  cicatrix  should  always 
be  resected.  The  ends  of  severed  tendons  should  likewise  be  re- 
sected, but  not  so  high  that  their  empty  sheaths  may  be  left  to  favor 
the  lodgment  of  infection. 

That  the  stump  may  be  sound  and  uniform  in  its  outline,  it  is  neces- 
sary that  the  different  degrees  of  contractility  of  the  various  groups 
of  divided  muscles  be  known  and  their  division  accomplished  accord- 
ingly so  that  finally  their  ends  may  occupy  the  same  level.  The 
bones  must  also  be  sawed  squarely  and  care  taken  that  the  division 
is  not  completed  by  fracture.  The  periosteum  must  not  be  roughly 
handled. 

The  technic  is  concerned  also  with  the  prevention  of  hemorrhage. 
This  is  best  secured  by  first  elevating  the  limb  for  several  minutes 
and  then  applying  an  Esmarch  tube  above  the  site  of  the  operation. 

After  the  section  of  the  limb  is  completed  and  the  large  vessels  se- 
cured and  ligated,  the  tube  must  be  removed  and  each  bleeding  point 
ligated  separately.  The  tube  has  the  disadvantage  that  there  is 
nearly  always  a  temporary  vaso-motor  paralysis  due  to  the  pressure, 
and  on  that  account  the  oozing  is  considerable. 

The  occasional  surgeon  will  be  called  upon  to  do  amputations 
under  two  entirely  different  circumstances,  and  his  mode  of  proced- 
ure will  be  quite  different  in  the  two  cases.  In  one  case,  he  will 
attempt  the  typical  amputation  of  the  text-book;  in  the  other,  his 
sole  guide  will  be  the  preservation  of  tissue:  he  will  do  an  atypical 
amputation. 

(A)  The  soft  parts  are  more  extensively  destroyed  than  the  bone. 
This  is  nearly  always  the  case  in  traumatism  and  always  the  case 
in  gangrene.  The  site  of  amputation  will  depend  upon  the  limit  of 
the  sound  skin;  the  rule  is  to  remove  none  of  the  healthy  soft  parts; 
the  line  of  incision  should  follow  the  line  of  demarcation,  and  having 
fashioned  the  flap  following  this  indication,  divide  the  bone  high 


730  SOME   PRACTICAL   AMPUTATIONS 

enough  lo  accommodate  the  flaps,  and  no  higher.     (See  also  Injuries 
to  the  Extremities.) 

(B)  In  case  the  bone  is  more  extensively  destroyed  than  the 
soft  parts,  as  in  tuberculosis,  sarcoma,  etc.,  one  has  more  option;  he 
can  fashion  the  flaps  in  any  manner  desired,  for  usually  much  that  is 
healthy  will  have  to  be  removed.  The  position  of  the  cicatrix  can  be 
determined  and  such  is  the  typical  amputation. 

FINGER  AMPUTATIONS 

Practical  anatomical  points  (Jacobson,  Operative  Surgery) : 
''The  three  creases  in  front  almost  correspond  to  the  joints.     The 
lower  crease  is  just  above  the  joint;  the  middle  is  opposite  the  joint; 
the  highest,  nearly  ^:4  of  an  inch  distal  to  the  metacarpo-phalangeal 
joint. 

''  The  prominence  of  the  knuckles  is  formed  by  the  higher  of  the  two 
bones;  by  the  head  of  the  metacarpal  bone,  the  head  of  the  first  pha- 
lanx, the  head  of  the  second  phalanx  for  the  three  joints  respectively. 


Fig.  559. — Typical  amputation  of  finger;  palmar  flap,  dorsal  scar.     {Farabeuf.) 

''The  joint  in  each  case  is  below,  or  distal  to,  the  prominence;  the 
metacarpo-phalangeal  joint  is  about  J^  inch  below  the  knuckle; 
the  second  joint,  J^  inch  below  the  knuckle;  the  terminal  joint  J^2 
inch  beyond  the  knuckle. 

"In  the  distal  and  interphalangeal,  the  joint  is  concave  from  side  to 
side  and  presents  a  concavity  toward  the  finger  tips.  In  the  meta- 
carpo-phalangeal joint,  the  convexity  is  toward  the  finger  tip. 

"From  the  readiness  with  which  the  tendons  conduct  infection, 
care  should  be  taken  to  keep  even  so  small  an  amputation  as  that  of  a 
finger  strictly  sterile,  and  in  amputating  through  damaged  parts  the 
flaps  should  not  be  too  closely  united  with  sutures." 

It  is  a  rule  with  but  few  exceptions  to  save  as  much  of  the  finger  as 
possible,  and  it  will  almost  always  happen  in  removing  part  of  a  finger 


AMPUTATION    OF    FINGER 


731 


that  an  atypical  amputation  will  be  indicated.  Let  the  scar  fall 
where  it  will,  making  a  dorsal  or  a  lateral  flap  if  necessary.  The 
palmar  flap  and  dorsal  scar  is  ideal,  but  rarely  attainable  (^Fig.  562). 
There  are,  however,  surgeons  of  large  experience  who  insist  that  a 
palmar  flap  be  secured  even  at  the  cost  of  more  finger,  and  that  less 
than  half  a  phalanx  should  not  be  saved,  but  cut  back  to  the  joint 
to  avoid  flexure.     (See  Injuries  to  the  Hand.) 

If  a  distal  phalanx  is  to  be  removed,  begin  by  pronating  the  hand, 
forcibly  flex   the  phalanx  and  divide  the  skin   }'?  inch  distal  to 


Fig.  560. — Atypical  amputation  of  a  finger,  the  bone  projecting  beyond  the  skin.      Dorsal 

incision.     (Veau.) 


the  knuckle;  this  incision  deepened  will  open  the  joint.  Divide  the 
lateral  ligaments.  The  edge  of  the  knife  is  carried  under  the  phalanx 
and  swept  downward,  grazing  the  bone  and  cutting  with  a  steady 
sawing  movement.  The  result  is  indicated  in  Fig.  559.  Do  not  cut 
the  flap  too  short,  a  common  mistake  with  the  inexperienced. 

AN  ATYPIC.\L  AMPUTATION 

Suppose  a  finger  to  have  been  sawed  off.  The  bone  projects  be- 
yond the  retracted  skin.  It  is  not  possible  to  fashion  a  flap  without 
removins:  some  bone. 


732 


SOME   PRACTICAL   AMPUTATIONS 


Local  anesthesia  (Figs.  loand  ii).  Circular  constriction  at  the  base 
will  control  bleeding  and  prevent  rapid  absorption  of  the  solution. 
Begin  by  making  a  dorsal  linear  incision  an  inch  long  down  to  the 
bone   (Fig.    560). 

Liberate  the  whole  circumference  of  the  bone  }i  inch  up, 
either  with  a  rugine  or  a  bistoury  (Fig.  561),  and  at  that  level  divide 
the  bone  with  bone  forceps  (Fig.  562).  Fmploy  two  or  three  sutures 
with  drainage  if  there  is  much  chance  of  infection  (Fig.  563). 

If  the  dorsal  linear  incision  opens  into  a  joint,  the  section  may  be 
made  there — disarticulate. 


Fig.  561. — Liberating  the  bone.     (Veau.) 


Fig.   562. — Section  of  the  bone.       {Veau.) 


Divide  first  the  dorsal  ligament,  then  the  lateral  ligament  to  the 
left,  and  as  the  phalanx  is  twisted  toward  the  left,  divide  the  lateral 
ligament  to  the  right.  Suture  as  before.  It  may  be  necessary  to 
slice  off  the  head  of  the  remaining  portion  of  the  digit  if  it  is  too 
prominent. 


TYPICAL  AMPUTATION  OF  THE  WHOLE  FINGER 

General  anesthesia  is  usually  necessary.  The  method  of  procedure 
is  different  for  the  middle  and  ring  fingers,  the  index  and  little  fingers, 
and  the  thumb. 


AMPUTATION   OF   FINGER 


733 


(I)  The  Middle  and  Ring  Fingers. — ^Locate  the  articular  line  by 
making  traction  on  the  finger  with  one  hand  and  palpating  each  side 
of  the  joint  with  the  index  finger  and  thumb  of  the  other  hand. 


Fig.  563. — Atypical  amputation:  Suture  and  drainage.     (Veau.) 


Fig.  564- — Typical  amputation  of  middle  finger:    Primary  incision  directed  to 

the  right.      (Veau.) 

Begin  the  incision  at  the  upper  level  of  the  joint;  carry  it  obliquely 
downward  and  forward  between  the  fingers  so  that  it  reaches  the 
palmar  surface  at  the  right,  a  little  below  the  crease  (Fig.  564). 


734 


SOME   PRACTICAL   AMPUTATIONS 


Lift  up  the  hand  so  that  3'ou  face  the  palm  and  cut  transversely  to 
the  left  (Fig.  565).  Now  lower  the  hand  and  complete  the  incision, 
bringing  it  obliquely  upward  and  backward  to  the  knuckle,  the  start- 
ing-point (Fig.  566). 

Having  outlined  the  incision  in  this  manner,  repeat  the  movement, 
cutting  to  the  bone.     Retract  the  flap,  exposing  the  articulation. 


Fig.   565. — Amputation  of  the  middle  finger:  Lifting  the  hand  while  making  the  transverse. 

palmar  incision.     (Veau.) 


Disarticulate.  Pull  on  the  finger  to  separate  the  joint  surfaces, 
which  helps  to  locate  the  joint  line.  Hold  the  bistoury  vertically, 
and  with  its  point  divide  the  lateral  ligament  to  the  left,  then  the 
dorsal  ligament  (Fig.  567),  then  the  ligaments  to  the  right,  at  the 
same  time  bending  the  finger  to  the  right. 

Tie  the  digital  arteries,  usually  one  on  each  side,  and  suture 
(Fig.  568). 


AMPUTATION    OF    F1N(;j:K 


735 


(II)  Index  and  Little  Fingers. — In  these  two  instances,  the  aim 
is  to  carry  the  scar  toward  the  dorsum  and  the  axis  of  the  hand.     In 


Fig.  566. — Amputation   of   the    middle   finger.     Completing   the   skin   incision.     (Veau.) 


K 


Fig.  567. — Amputation  of  the  middle  finger:      Traction  on  the  finger  while  the  bistoury  cuts 
first  the  left  and  then  the  dorsal  ligaments.     {Veau.) 

the  case  of  the  index,  it  falls  toward  the  ulnar  side;  in  the  case  of  the 
little  finger,  toward  the  radial  side.  The  scar  is,  then,  in  each  case, 
furthest  removed  from  pressure. 


736 


SOME  PRACTICAL  AMPUTATIONS 


The  flap  itself,  of  rounded  outline,  folds  over  on  an  axis  passing 
obliquely  through  the  joint  cavity  and  approximates  the  adjoining 
finger. 

The  removal  of  the  index  finger  is  conducted  along  the  same  lines. 

The  first  semicircular  incision  is  carried  around  the  radial  side  and 
completed  by  a  second,  following  the  web  of  the  finger.  The  appear- 
ance of  the  flap  is  indicated  in  Fig.  573,  and  the  final  result  in  Fig.  574. 


Fig.  568. — Amputation  of  the  middle  finger  completed.     (Veau.) 

If  the  patient  is  a  laborer,  it  is  necessary  to  render  the  hand  as  use- 
ful as  possible,  nor  must  the  cosmetic  effect  be  neglected.  It  is  neces- 
sary to  reduce  the  size  of  the  heads  of  the  metacarpal  bones. 

The  head  of  the  metacarpal  bone  of  the  index  is  best  reduced  by  an 
obhque  section  of  the  radial  side;  of  the  httle  finger,  the  ulnar  side; 
of  the  ring  finger,  by  transverse  section  (Fig.  575).     With  regard  to 


AMPUTATION    OF    LITTLE    FINGER 


737 


Fig.  569. — Amputation  of  the  little         Fig.  570. — Amputation  of  the  little  finger:  Disar- 
finger:   Flaps  completed.     {Veau.)  ticulation,  cutting  from  left  to  right.     (Veau.) 

In  the  case  of  the  little  finger,  begin  the  incision  just  below  the  joint  line  on  the  ulnar 
side  of  the  extensor  tendon,  and  carry  it  obliquely  downward  and  forward  and  then  across 
the  palmar  surface,  inscribing  a  regular  semicircle  which  ends  at  the  free  border  of  the  web 
between  the  little  and  ring  fingers.  Complete  the  incision  by  cutting  from  this  point  to  the 
starting-point,  inscribing  a  semicircle  with  its  concavity  toward  the  web.  Follow  this  same 
track  again,  cutting  to  the  bone.     Denude  the  bone  completely  (Fig.  569). 

Disjoint,  dividing  the  left  and  the  dorsal  and  finally,  the  right  lateral  ligament  (Fig. 
(570),  and  the  flap  is  free  (Fig.  571).      Suture  (Fig.  572). 


Fig.  5  71. — Amputation  of  the 
Flap  after  disarticulatin. 

47 


little  finger : 
(Veau.) 


Fig.  572. — Amputation  of  the  little  finger: 
flap  sutured.  The  line  of  union  lies  toward 
the  axis  of  the  hand  on  the  dorsum.  (Veau.) 


738 


SOME   PRACTICAL   AMPUTATIONS 


the  middle  finger,  the  head  of  its  metacarpus  should  not  be  removed 
unless  shapeliness  rather  than  strength  is  desired  (see  page  105). 

(Ill)  The  Thumb. — The  thumb  must  be  treated  with  the  utmost 
conservatism.  The  smallest  part  must  never  be  removed  unneces- 
sarily, as'it  is  almost  as  useful  as  the  rest  of  the  fingers  together, 


7/  ''      ' 


Fig.  573. — Amputation    of    index;    showing     Fig.  574- — Amputation  of  index  and  little 
form  of  flap.     (Veau.)  fingers  completed.     (Veau.) 


and  nearly  always  after  a  traumatism,  it  is  best  to  do  an  atypical 
amputation.     (Figs.  582,  583,  584.) 

In  the  typical  amputation,  employ  a  palmar  flap.  Begin  on  the 
dorsal  surface  just  below  the  articular  fine  and  incise  to  the  right, 
reaching  the  edge  of  the  palmar  surface  just  above  the  interphalan- 
geal  crease.     (Fig.  580.) 


SECTION   OF   THE   METACARPALS 


739 


In  the  course  of  a  finger  amputation,  once  the  finger  is  disarticulated  at  the  metacarpo- 
phalangeal joint  (amputation  of  whole  finger),  the  treatment  of  the  corresponding  meta- 
carpal head  is  to  be  considered. 

The  mode  of  procedure  varies  with  the  various  fingers  and  is  determined  by  two 
factors:      The  future  appearance  of  the  hand;  and,  second,  its  usefulness. 

Fortunately  the  best  cosmetic  effect  is  consistent  for  the  most  part  with  conservation 
of  function.  Formerly  we  were  advised  to  leave  the  metacarpal  head  intact  whenever 
it  was  desired  to  maintain  the  whole  strength  of  the  hand.  This  was  based  on  the 
notion  that  destroying  the  transverse  ligaments  left  the   metacarpus  unstable  and  the 


Fig.  575. — Lines  of  section  of  the  metacarpal  heads.     (Veau.) 


hand  weakened  in  consequence;  but  the  line  of  section  need  not  extend  so  far  beyond 
the  articular  surface.  The  line  of  section  diflfers  with  the  various  digits  as  indicated  in 
Fig.  575. 

Thus  the  metacarpal  head  of  the  index  and  little  fingers  is  sectioned  obliquely  to 
smooth  off,  in  the  one  case  the  radial,  in  the  other,  the  ulnar  border  of  the  hand.  Com- 
pare Fig.  574  with  figures  on  page  102. 

The  Ring  Finger. — Divide  the  metacarpal  head  cransversely  (see  page  103). 

The  Middle  Finger. — The  metacarpal  head  is  best  treated  by  slicing  oflf  a  part  of  each 
lateral  surface.  If  none  is  removed  the  separation  of  the  adjacent  fingers  is  too  wide 
Fig.  568">.  If  too  much  is  removed  the  index  finger  falls  away  from  the  thumb  inter- 
f erring  with  apposition  (see  page  104). 


740 


SOME  PRACTICAL  AMPUTATIONS 


Fig.  576. — Crush  of  ring  finger.    Treatment. 


Every  crush  of  the  fingers  must  be  treated  with  the  greatest  conservatism.  The 
temptation  to  get  rid  of  the  mangled  tissues  and  to  make  a  sightly  stump  is  always 
great  but  the  patient's  mind  dwells  more  strongly  on  the  loss  of  tissue.  In  many  cases 
it  is  impossible  to  say  what  effort  the  tissues  may  make  toward  repair.  Trim  the  skin 
sparingly  therefore.  Carefully  disinfect  and  splint  in  such  manner  as  not  to  interfere 
with  the  circulation  and  wait  for  further  indications. 

However,  a  finger  crushed  in  the  manner  indicated  in  Fig.  576,  it  is  useless  to  save, 
because  it  will  be  deformed,  unsightly  and  an  actual  hindrance.  Usually  the  tissues 
slough  and  there  is  constant  danger  of  infection  involving  the  whole  hand.  It  is  best  to 
disarticulate  at  once  at  the  metacarpo-phalangeal  joint. 

Begin  with  a  dorsal  incision  extending  1/2  inch  above  the  head  of  the  metacarpal 
bone,  freely  exposing  the  extensor  tendon.  The  incision  is  now  carried  around  the  base 
of  the  finger  (Fig.  577). 


AMPUTATION   OF   FINGER 


741 


Fig.  577. — Crush  of  ring  finger.     Amputation. 

Second  step:  Raise  the  finger  so  that  the  palmar  surface  presents  and  beginning  at  the 
dorsal  incision  cut  from  left  to  right  along  the  base  of  the  finger  keeping  within  the  limits 
of  sound  tissue.  Cut  down  to  the  bone,  dividing  the  flexor  tendons  and  on  either  side 
the  digital  arteries.  Having  divided  all  the  soft  parts  denude  the  bone  with  a  rugine  or 
periosteal  elevator,  exposing  the  head  of  the  metacarpus  thoroughly   (Fig.  578). 

Third  step:  Disarticulate  by  dividing  the  ligaments,  first  the  dorsal,  then  the  right 
lateral,  and  the  left.  The  joint  is  now  widely  opened  so  that  the  palmar  ligaments  are 
exposed  and  easily  divided  (Fig.  578). 

Fourth  step:  Resection  of  the  Metacarpal  head.  Grasp  the  exposed  bone  with  a  bone- 
holding  forceps  and  divide  it  transversely  with  a  saw  or  bone  shears  (Fig.  579)-  Com- 
plete the  hemostasis,  ligating  the  digital  arteries.    Suture. 


742 


SOME   PRACTICAL   AMPUTATIONS 


Fig.  578. — Crush  of  ring  finger.    Third  step  in  amputation.      {Lejars.) 


Fig.  579.— Crush  of  nng  finger.    Fourth  step  in  amputation.      (Lejars.) 


AMPUTATION    OF   FINGER 


743 


Fig.   580. — Line  of  incision  in  typical  am-        Fig.   581. — Lines  of  incision  in  removing 
putation  of  the  thumb.    iFarabeuf.)a.  a  finger  with  its  metacarpus.     {Veau.) 

The  line  of  incision  in  typical  amputation  of  the  thumb  should  mark  off,  if  possible,  a 
palmar  flap  (Fig.  580).  Begin  the  incision  on  the  dorsal  surface  below  joint  line.  Cut  to 
the  right,  reaching  the  palmar  surface  at  the  interphalangeal  crease.  Continue  the  in- 
cision across  the  palmar  surface.  Now  go  back  to  the  starting  point  and  make  an  incision 
similar  to  first  on  the  opposite  side,  completing  outline  of  flap.  While  the  assistant  now 
steadies  thumb,  dissect  the  flap  including  all  the  soft  oarts  down  to  the  bone,  dividing 
the  flexor  tendon  and  finally  exposing  the  joint.  Let  the  assistant  now  retract  the  flap 
while  you  pull  on  the  thumb  bringing  the  joint  line  into  relief.  Section  the  ligaments  to 
the  left,  above  and  to  the  right  successively.     Drain  and  suture. 

Trace  of  incision  for  removing  the  finger  with  its  metacarpal.  Note  that  incision  begins 
on  the  back  on  the  line  connecting  the  bases  of  the  metacarpal  bones  of  thumb  and  little 
finger;  extends  along  dorsum  of  metacarpus  and  branches  above  level  of  its  head  Fig.  581). 
The  head  of  the  metacarpus  is  cleared  and  the  denudation,  sometimes  difficult,  carried 
toward  the  wrist.  The  point  of  the  knife  is  inserted  in  the  joint  lines  to  disarticulate. 
Care  must  be  taken  to  avoid  the  deep  palmer  arch  which  lies  adjacent. 


744 


SOME   PRACTICAL   AMPUTATIONS 


;,'.>!f/,^r. 


^;:\.//;\ij!ir,(Mj/!A, 


Fig.   582. — Crush  of  the  Thumb. 
Atypical  amputation. 


Fig.   583. — Crash  of   Thumb.     Atypical 
amputation.      First  step. 


A  crushed  thumb  must  be  treated  with  the  greatest  conservatism  since  even  the  shortest 
stump  is  useful,  the  metacarpal  bone  has  all  the  value  of  a  phalanx  in  the  other  digits 
(Fig.  582). 

Do  an  atypical  amputation.  Let  the  primary  incision  follow  the  line  of  viable  tissue, 
cutting  down  to  the  bone.  Denude  the  bone  with  the  rugine  (Fig.  583).  Resect  so 
that  the  skin  flaps  will  fall  into  place  without  undue  stretching. 

It  must  be  remembered  that  the  vitality  of  the  flaps  is  lowered  and  if  they  are  stretched 
tightly  over  the  end  of  the  bone  are  sure  to  slough.  The  drainage  must  be  ample  (Fig. 
S84). 


AMPUTATION   OF   FOREARM 


745 


ATYPICAL    AMPUTATION    OF    THE   HAND      (Traumatism 
of  the  Metacarpals)   (Fig.  585) 

It  is  often  inadvisable  to  amputate  at  once,  for  parts  that  seem 
devitalized  may  survive.  Check  the  hemorrhage  and  disinfect  and 
await  the  course  of  events.  The  limits  of  viable  tissue  can  soon 
be  determined.  The  technique  is  sufficiently  indicated  in  Figs. 
585,  586,  587,  588,  589. 


AMPUTATION  OF  THE  FOREARM 

Disarticulation  at  the  wrist  is  very  rarely  done  in  general  practice. 
If  a  tuberculosis  of  the  wrist  calls  for  intervention,  amputate  the 
forearm  (Fig.  590). 


Fig.  584. — Atypical  amputation  of  the  thumb  complete;  part  of  metacarpus  preserved. 

Drainage.     {Lejars.) 

Following  traumatism,  do  an  atypical  amputation,  conserving  as 
much  as  possible  of  the  member. 


746 


SOME  PRACTICAL  AMPUTATIONS 


Fig.  585. — Crushing  injury  to  hand.     Useless  to  try  to  save  any  but  the  index 

finger.     {Veau.) 


Fig.  586. — The  metacarpals  are  denuded  upward  for  an  inch;  all  the  soft  parts 

saved.     {Veau.) 


AMPUTATION    OF   HAND 


747 


Fig.  587. — Section  of  metacarpals  with  bone-cutting  forceps.     (Veau.) 


In  the  case  of  a  crush  of  the  hand  involving  the  metacarpus,  no  eflFort  is  made  to  do 
a  typical  amputation;  the  whole  effort  is  to  save  as  much  useful  tissue  as  possible. 
As  indicated  in  Fig.  586  denude  the  bones  as  high  up  as  the  skin  flaps,  after  having 
been  properly  trimmed,  require.  Sometimes  it  will  be  advisable  to  wait  for  a  day  or 
two  to  see  how  much  of  the  soft  parts  will  live.  Accordingly  the  hand  is  carefully  dis- 
infected. A  moist  antiseptic  dressing  is  applied  and  kept  under  close  observation  until  a 
line  of  demarcation  occurs. 

Once  the  level  of  bone  section  is  determined  resect  with  bone  forceps,  suture  loosely 
with  ample  drainage,  but  be  sure  of  the  hemostasis. 

If  infection  develops,  remove  the  sutures  and  use  prolonged  immersion  in  hot  normal 
salt  solution. 


748 


SOME   PRACTICAL   AMPUTATIONS 


Typical  amputations  of  the  forearm  are  most  easily  performed  at 
any  level,  by  a  modified  circular  incision;  for  Technic,  see  Figs.  591, 
592,  593)  594,  595;  596,  597,  598. 


Fig.  588. — Amputation  completed.     {Veau.) 


AMPUTATION  AT  THE  ELBOW- JOINT 

Make  a  circular  incision  3  inches  below  the  joint,  involving  the 
skin  and  fascia.  Turn  back  the  cuff  to  the  joint.  Divide  the  mus- 
cles over  the  joint  hne.  Divide  the  lateral  ligaments.  Open  the 
outer  side  of  the  joint  first  and,  directing  the  assistant  to  make  trac- 
tion on  the  arm,  separate  the  ulna  and  divide  the  triceps.  Tie  the 
arteries,  resect  the  nerves,  and  suture. 


AMPUTATION   AT   SHOULDER  JOINT 


749 


Fig.  589. — Am- 
putation of  the 
hand.  Thumb 
saved.     {Senn.) 


AMPUTATION  OF  THE  ARM 

Apply  an  Esmarch  tube  high  up  near  the  axilla, 
or  an  assistant  may  compress  the  artery  in  the 
upper  part  of  the  arm  or  behind  the  clavicle. 

Stand  to  the  outer  side  of  the  arm.  Retract  the 
skin  with  the  left  hand  if  operating  on  the  right 
arm,  or  direct  the  assistant  to  retract  the  skin  if 
operating  on  the  left  arm.  The  skin  section  must 
lie  about  one  diameter  below  the  proposed  bone 
section  (Fig.  599).  The  successive  steps  of  the 
operation  are  indicated  in  Figs.  599,  600,  601,  602, 
603. 

AMPUTATION  AT  THE 
SHOUT.DER-JOINT 

Amputation  at  the  shoulder  may  be  per- 
formed by  a  variety  of  methods,  each  of  which 
has  its  advantages  and  disadvantages.  The 
special  points  to  be  thought  of  in  making  the 
operation  are  the  control  of  hemorrhage,  good 
drainage,  easy  disarticulation  and  a  good  stump. 
No  one  operation,  perhaps,  secures  all  of  these 
principles    in  equal  degree. 

Spence's  method  is  recommended  as  generally 
serviceable. 

Recall  the  principal  landmarks  of  the 
shoulder- joint,  the  acromion  process,  the  cora- 
coid,  the  tuberosities;  recall  the  attachments 
of  the  various  muscles;  and  the  relations  of  the 
blood  vessels. 

The  patient  is  placed  with  his  shoulder  close 
to  the  edge  of  the  table,  with  shoulder  elevated, 
and  face  turned  to  the  opposite  side.  The 
operator  stands  to  the  outer  side. 

The  operator  aims  at  the  exposure  of  the  joint 
and  disarticulation,  and  finally  the  formation  of 
an  axillary  flap. 


Fig.  590. — Amputa- 
tion of  the  forearm. 
Tuberculosis  of  the 
wrist.     {Veau.) 


750 


SOME  PRACTICAL  AMPUTATIONS 


Fig.  591. — Amputation  of  the  forearm      Beginning  the  circular  incision,  which  must  fall 
well  below  proposed  line  of  bone  section. 


Fig.  592. — Amputation  of  the  forearm.     Completing  the  circular  incision.     Not  only  the 
♦  skin  but  the  fascia  as  well  must  be  completely  divided. 


AMPUTATION    OF   FOREARM 


751 


Fig.  593. — Lateral  incisions  extending  upward  two  or  three  fingers'  breadth,  favor 

retraction  of  skin  cuflf. 


Fig.  594. — Third  step.     Transfix  muscles  at  upper  level  of  lateral  vents,  point  of  knife 
grazes  bones.     Hand  must  be  supinated  and  flexed  to  relax  muscles  of  forearm. 


752 


SOME   PRACTICAL   AMPUTATION'S 


Fig.  595. — Complete  the  anterior  flap  bj' cutting  outward  following  the  transfixion.  Re- 
peat the  process,  passing  the  transfixing  blade  posterior  to  bones  and  fashion  posterio;  flap 
in  same  manner.     (Veau.) 


Fig.  596. — The  flaps  formed,  it  remains  to  divide  the  interosseous  membrane  and  at- 
tached muscles,  and  the  periosteum.  The  direction  which  the  point  of  knife  takes  is  indicated 
by  the  arrows. 


AMPUTATION   OF  FOREARM 


753 


Fig.  598. 
Fig.  600  shows  manner  in  which  the  periosteum  is  stripped  back  after  all  the  soft  parts 
are  divided.  The  bones  are  completely  denuded  to  level  of  section  previously  determined. 
Use  a  three-tailed  retractor  to  pull  the  skin  flaps  out  of  the  way  of  the  saw  partly  divide 
the  ulna,  saw  through  the  radius  and  complete  section  of  the  ulna.  Ligate  all  vessels,  trim 
the  median  and  ulnar  nerves.  Fig.  601  shows  the  manner  of  applying  drainage  which  should 
nearly  always  be  used,  and  of  suturing  the  skin  flaps. 
48 


754  SOME   PRACTICAL   AMPUTATIONS 

Incision. — (i)  Begin  just  in  front  of  the  coracoid  process  and  cut 
vertically  downward  to  the  lower  level  of  the  tendon  of  the  pectoralis 
major,  keeping  in  front  of  the  groove  between  the  pectoralis  major 
and  deltoid.  This  incision  should  reach  the  bone;  the  pectoralis 
major  tendon  is  divided.  The  bleeding  comes  from  the  humeral 
branches  of  the  acromio-thoracic  and  from  the  anterior  circumflex. 
These  vessels  may  be  clamped. 

(2)  Next  carry  the  incision  outward  across  the  arm,  making  a 
slight  curve,  convex  downward,  and  ending  at  the  axillary  border 
behind.  All  the  structures  are  divided  to  the  bone.  The  deltoid  is 
divided  just  above  its  insertion  and  the  hemorrhage  comes  from  the 
muscular  branches. 

The  next  step  consists  in  outlining  the  internal  flap  by  making  an 
oval  skin  incision,  which  extends  from  the  termination  of  the  first 
across  the  inner  surface  of  the  abducted  arm  to  the  end  of  the  vertical 
part  of  the  first  incision  (Fig.  604). 

The  third  step  consists  in  elevating  the  external  flap  which  con- 
tains the  deltoid.  It  is  easily  dissected  and  by  this  means  the  joint 
is  exposed.  The  posterior  circumflex  artery  must  not  be  injured 
and  is  preserved  in  the  deltoid  flap. 

The  fourth  stage:  Disarticulate.  Begin  by  dividing  the  biceps 
tendon  and  the  capsule  with  a  transverse  cut.  Rotate  the  arm  in- 
ward and  divide  successively  the  tendons  of  the  teres  minor,  the  in- 
fraspinatus, the  supraspinatus;  rotate  the  arm  outward  and  divide 
the  tendon  of  the  subscapularis.  If  the  humerus  has  been  broken, 
rotate  the  head  by  means  of  a  bone  forceps. 

Dislocate  the  head,  divide  the  capsule  behind  and  push  the  head 
up  to  the  level  of  the  acromion;  drawing  the  head  outward,  slip  the 
knife  behind  the  head  and  prepare  to  complete  the  section  of  the 
soft  parts.  If  the  axillary  has  not  been  previously  ligatcd,  the  assist- 
ant grasps  the  upper  part  of  the  flap  about  to  be  divided  and  his 
hands  follow  the  knife  downward  ready  to  compress  the  artery  as 
soon  as  divided. 

The  knife  follows  the  bone  till  opposite  the  skin  incision  when  it 
cuts  directly  through  the  soft  parts  that  the  vessels  may  not  be  di- 
vided obliquely.     The  arm  is  now  completely  removed. 

The  next  step  consists  in  ligating  the  vessels  and  in  trimming  the 


AMPUTATION    OF    ARM 


755 


Fig.  599. — Amputation  of  the  Arm.  Circular  flap.  (Veau.) 
Supposing  an  amputation  af  the  right  arm,  grasp  the  arm  above  the  proposed  incision, 
with  left  hand,  pulling  the  skin  tight  while  the  assistant  supports  the  member.  First 
step;  Make  a  semicircular  cut  from  the  inside,  over  the  front  and  to  the  outside.  Repeat, 
passing  from  the  inside  behind  the  arm.  Avoid  wounding  the  artery  on  the  inside. 
Divide  the  skin  and  fascia  only.  There  will  be  considerable  venous  hemorrhage  which  is 
to  be  disregarded.  There  will  be  about  an  inch  gap  when  the  skin  and  fascia  are  com- 
pletely divided.     The  next  step  is  liberation  and  further  retraction  of  the  skin  flap. 


7S6 


SOME   PRACTICAL  AMPUTATIONS 


Fig.  600— Amputation  of  the  arm.      Circular  flap.      (Veau.) 

Second  step:  Free  the  skin  flap.  Divide  the  fascial  attachments  with  the  point  of  the 
knife  but  do  not  button-hole  the  skin  flap.  The  fascial  attachments  are  firmest  over  the 
line  of  the  artery  and  a  little  patience  is  necessary  in  freeing  them.  Loosen  the  skin  until 
there  is  a  gap  of  at  least  j\i  inches.  The  flap  must  be  well  mobilized.  You  are  ready 
now  to  make  a  circular  section  of  the  muscles. 


AMPUTATION   OF  ARM 


757 


Fig.  6oi. — Amputation  of  the  arm.      Circular  flap. 


Third  step:  First  circular  section  of  the  muscles.  The  soft  parts,  skin  and  muscles  are 
to  be  strongly  retracted,  either  by  the  operator's  left  hand  or  by  an  assistant.  By  a  circu- 
lar sweep  of  the  knife  divide  the  muscles  at  the  level  of  the  retracted  skin.  Divide  all 
the  structures  down  to  the  bone.  But  they  do  not  contract  evenly;  therefore  a  second 
circular  section  is  required. 


7S8 


SOME   PRACTICAL   AMPUTATIONS 


PiQ    5o2 Amputation  ortte  arm.     Second  circular  section  of  the  muscles. 


Fig.  603. — Amputation  of  the  arm.  Denudation  of  the  periosteum. 
Fourth  step:  Second  circular  section  of  soft  parts  at  level  of  retracted  skin,  forming  a 
stump  with  a  smooth  even  surface  (Fig.  602).  The  blood  vessels  are  easily  identified 
and  should  be  ligated  at  this  time.  Fig.  603  shows  the  next  step  which  consists  in  the 
denudation  of  the  bone,  stripping  back  the  periosteum  to  the  level  of  the  proposed  bone 
section  when  the  bone  is  sawed.  Remove  the  tourniquet  and  complete  the  hemostasis. 
Suture  the  periosteal  flaps  over  the  bone  if  possible.  Mattress  suture  the  muscles  and 
fascia.     Drain.     Suture  the  skin. 


AMPUTATION    AT    SHOULDER 


759 


axillary  nerves  and  in  suturing  the  flaps  so  as  to  form  a  vertical  scar 
as  nearly  as  possible.     The  glenoid  fossa  may  be  curetted. 

For  the  control  of  hemorrhage,  Wyeth's  plan  of  constriction  may 
be  followed.  An  elastic  ligature  held  in  place  by  two  pins  passed 
through  the  soft  parts  before  and  behind  the  shoulder  compresses 
the  axillary  vessels. 


AMPUTATION  ABOVE  THE  SHOULDER 

This  operation,  bloody  and  often  fatal,  may  need  to  be  undertaken 
for  malignant  disease  in  the  vicinity  of  the  shoulder-joint  or  as  an 
emergency  in  the  case  of  crushing  injury  to 
the  shoulder  or  of  gunshot  wounds. 

The  procedure  as  defined  by  Berger  con- 
templates the  resection  of  the  middle  third 
of  the  clavicle  and  ligation  of  the  subclavian; 
the  formation  of  the  antero-inferior  and  a 
postero-superior  flap;  and  finally  the  division 
of  the  muscles  connecting  the  scapula  with 
the  trunk. 

The  operation  is  thus  described: 

Place  the  patient  on  his  back  close  to  the 
edge  of  the  table,  with  the  shoulder  slightly 
elevated.  Begin  the  incision  over  the  cla- 
vicle at  the  outer  border  of  the  sterno-mas- 
toid,  and  follow  the  clavicle  outward  to  the 
acrominal  end,  cutting  to  the  bone.  Denude 
the  middle  third  of  its  periosteum  with  the 

rugine,  and  divide  the  bone  at  the  junction  of  the  inner  and  middle 
thirds.  Elevate  the  bone  and  divide  again  at  the  junction  of  the 
middle  and  outer  third.  Separate  by  blunt  dissection  the  fascias 
overlying  the  subclavian  vessels  and  first  ligate  the  artery  at  the 
outer  border  of  the  first  rib  and  then  the  vein. 

Now  change  the  patient's  position:  the  shoulder  is  brought  over  the 
edge  of  the  table,  the  arm  abducted,  and  the  head  turned  to  the 
opposite  side. 

Form  the  antero-inferior  flap.     Begin  an  incision  at  the  middle  of 


Fig.    604. — Spence's    am- 
putation.     (Moullin.) 


760  SOME   PRACTICAL   AMPUTATIONS 

the  first  and  carry  it  obliquely  dowTiward  and  outward;  just  to  the 
outer  side  of  the  coracoid  process,  along  the  anterior  border  of  the 
deltoid,  to  the  axillary  border  and  thence  across  the  inner  surface  of 
the  arm  just  below  the  axillary  fold  and  thence  down  the  axillary 
border  of  the  scapula.  Divide  the  pectorals  and  the  latissimus  dorsi 
close  to  their  insertions.     Resect  the  nerves  of  brachial  plexus. 

Fro7n  the  postero-superior  flap.  Begin  the  incision  over  and  just 
internal  to  the  acromio-clavicular  joint  and  carry  it  downward  over 
the  spine  of  the  scapula  to  the  lower  angle  of  the  scapula,  where  it 
joins  the  preceding  incision.  Dissect  the  flap  and  expose  the  muscles. 
Divide  first  the  trapezius  and  then  with  heavy  scissors  divide  close 
to  the  bone,  the  muscles  attached  to  the  posterior  border,  the  serratus 
magnus,  the  rhomboideus  major  and  minor,  and  the  levator  anguH 
scapulae. 

The  arm  falls  away.  Complete  the  hemostasis  and  drain  through 
button-holes  in  the  flaps  in  the  axilla  and  scapular  region.  Bandage 
firmly  so  as  to  obliterate  the  cavities. 

AMPUTATION  OF  THE  TOES 

These  amputations  are  more  frequently  consequent  upon  trauma- 
tism; occasionally  for  deformity  or  other  painful  conditions. 

In  the  amputation  of  fingers,  as  much  as  possible  is  saved;  in  the 
amputation  of  toes,  the  whole  toe  is  nearly  always  removed.  In 
consequence,  these  amputations  are  usually  t^-pical,  for  one  does  not 
so  much  need  to  concern  bimseh  with  the  conservation  of  tissue. 

In  the  case  of  total  ablation  of  the  finger,  a  part  of  the  metacarpal 
head  must  usually  be  removed  to  enhance  function;  the  head  of  the 
metatarsals  must  always  be  saved,  where  possible,  to  preserve  the 
functions  of  the  foot. 

The  position  of  the  cicatrix  demands  more  attention  in  the  case  of 
the  toes.  A  special  effort  must  be  made  to  leave  the  scar  farthest 
from  pressure;  that  is,  dorsal  and  to  the  inner  side  with  reference  to 
the  axis  of  the  foot. 

Local  anesthesia  is  often  sufficient,  forming  an  anesthetic  ring 
around  the  entire  toe,  involving  the  skin.  The  injection  may  need 
to  be  renewed  for  the  deeper  tissues;  and  before  disarticulation, 
inject  the  joint. 


AMPUTATION   OF   TOE 


761 


AMPUTATION  OF  THE  GREAT  TOE 

In  amputation  of  the  great  toe,  the  flap  resembles  that  of  the  index 
finger  and  the  scar  adjoins  the  base  of  the  second  toe. 

Begin  by  locating  the  joint  line.  The  incision  commences  just 
below  this,  and  over  the  tibial  border  of  the  extensor  tendon,  and 
extends  with  a  slight  outward  convexity,  downward  and  forward  to 
the  interphalangeal  crease  on  the  plantar  surface  and  across  the  pal- 
mar surface  obliquely,  ending  at  the  web. 

Begin  on  the  dorsum  again  at  the  original  starting-point  and  with  a 
slightly  curved  incision,  join  the  ends  of  the  first  (Fig.  605). 


Fig.  605. — Lines  of  incision  for  am- 
putation of  big  toe.     (Farabeuf.) 


Fig.  606. — Amputation  of  big 
toe  completed.     {Farabeuf.) 


Fig.  607. 


Dissect  the  flap,  keeping  close  to  the  bone,  so  that  all  the  soft  parts 
shall  be  preserved  in  the  flap.  Divide  the  flexor  tendon — sometimes 
rather  difficult. 

Disarticulate.  Divide,  first,  the  lateral  ligaments  to  your  left,  then 
the  dorsal,  and  finally  those  at  your  right.  Divide  the  plantar  liga- 
ments, twisting  the  toe,  as  in  the  case  of  the  finger.  Employ  drain- 
age; pull  the  flap  into  position  and  suture.  The  shape  of  the  flap  and 
the  position  it  assumes  are  represented  in  Figs.  606  and  607. 


762  SOME   PRACTICAL   AMPUTATIONS 

AMPUTATION  OF  THE  LITTLE  TOE 

Incision. — Begin  at  the  inner  end  of  the  joint  Hne  and  cut  obliquely 
downward  and  outward,  meeting  the  plantar  surface  at  the  joint  line 
below,  and  then  backward  and  inward  toward  the  web  (Fig.  608). 
In  this  manner  a  convex  flap  is  formed  (Fig.  609).  Dissect  the  flap, 
preserving  in  it  all  the  soft  parts.     Expose  the  joint  line. 

Disarticulate.  ]\Iaking  vigorous  traction  on  the  toe,  divide  in 
regular  order  the  lateral,  the  dorsal,  the  lateral  (to  your  right),  and 
plantar  hgaments. 


Fig.  608.  Fig.  609.  Fig.  610. 

Figs.  608  to  610. — Amputation  of  the  little  toe.      {Farabeuf.) 

Drain  from  the  upper  part  of  the  incision  and  suture.  The  posi- 
tion of  the  cicatrix  is  represented  in  Fig.  6io. 

AMPUTATION  OF  ONE  OF  THE  MEDIAN  TOES 

Incision. — The  hne  of  the  joint  having  been  determined,  begin  just 
above  it  on  the  dorsum,  incising  forward  and  downward  to  just  be- 
low the  web,  crossing  the  palmar  surface  and  back  to  the  starting- 
point,  completing  the  racket  (Fig.  6ii).  Remember  that  themeta- 
tarso-phalangeal  joint  is  considerably  above  the  line  of  the  web. 
Denude  and  divide  the  flexor  tendon. 

Disarticulate  in  the  manner  already  described  for  the  other  toes. 
Drain  from  the  upper  end  of  the  incision  and  suture  (Fig.  612). 


AMPUTATION    OF   TOE 


763 


Fig.  611. — Line  of  incision  for  amputation        FiG.  612. — Suture  and  drainage  after 
of  toe.     (Veau.)  amputation.     (^Veau.) 


Fig.  613. — Lines  of  incision  for  removal  of  toes  with  Head  of  corresponding 

metatarsals.      (Veau.) 


764 


SOME   PRACTICAL   AMPUTATIONS 


AMPUTATION  OF  A  TOE  WITH  PART  OF  ITS 
METATARSUS 

This  amputation  presents  some  difficulties  in  dissecting  the  flaps, 
because  of  the  palmar  projection  of  the  head  of  the  metatarsal. 

The  incision  is  racket-shaped,  as  in  amputation  of  the  toe,  but  it 
begins  higher  up,  above  the  level  of  the  diseased  bone,  and  runs  down 
to  the  web,  across  the  palmar  surface  and  back  to  the  starting-point, 
as  represented  in  Fig.  613.  To  dissect  the  flaps  for  the  middle  toes, 
denude  the  dorsum  of  the  metatarsus  and  divide  it  with  the  bone  for- 


FiG.  614, — Amputation  of  big  toe  with  head  of  metatarsal.     (Farabeuf.) 

ceps,  and  lifting  upon  the  divided  end,  dissect  forward  along  the  pal- 
mar surface. 

The  metatarsus  of  the  little  and  great  toes  may  be  sawed.  In 
forming  the  flap  for  the  great  toe  and  its  metatarsus  (Fig.  614)  do  not 
forget  to  remove  the  sesamoid.  Drain  as  in  amputation  of  the  toes, 
and  suture. 


AMPUTATION  OF  A  PART  OF  THE  FOOT 

As  in  the  case  of  the  hand,  the  rule  is  to  conserve  as  much  as  pos- 
sible of  the  foot  with  this  proviso,  that  a  painful  mass  of  scar  tissue 
does  not  form  in  the  stump  and  the  action  of  the  flexors  of  the  foot  is 
retained. 

In  the  case  of  traumatism  or  gangrene,  where  the  soft  parts  are 
more  involved  than, the  bone,  the  line  of  section  follows  the  healthy 
skin  and  the  bone  section  will  be  made  to  accommodate  itself  to  the 
skin  flaps. 

Atypical  Amputation, — ^If  the  case  is  one  of  tuberculosis,  the  bone  is 


AMPUTATION   OF   TOOT 


765 


more  involved  than  the  skin,  and  one  may  determine  the  upper  limit 
of  the  diseased  bone  and  divide  it  there.  In  such  a  case,  one  may 
fashion  a  palmar  flap,  and  make  a  dorsal  scar — the  typical  amputa- 
tion. But,  as  Veau  says,  do  not  concern  yourself  with  the  formal 
operations,  such  as  a  Lisfranc  or  a  Chopart — excellent  exercises  on 


Fig.  615. — Following   the    line    of   demarca- 
tion.    Atypical  amputation.     {Veau.) 


Fig.  616. — Dividing  the  bones.    (Veau.) 


the  cadaver — but  saw  the  bones  where  you  must,  to  remove  all  the 
disease. 

In  the  case  of  gangrene  or  traumatism,  then,  divide  the  tissues  to 
the  bone,  along  the  line  of  demarcation. 

The  borders  of  the  palmar  and  dorsal  flaps  must  correspond  to 
the  borders  of  the  foot  (Fig.  615).     Once  the  soft  parts  are  divided, 


766 


SOME   PRACTICAL   AMPUTATIONS 


they  should  be  retracted  by  dividing  their  attachments  close  to  the 
bone,  and  the  bones  are  divided  high  enough  for  the  flaps  to  come 
together  (Fig.  6i6). 
In  the  case  of  tuberculosis  make  a  transverse  incision  dorsally  and 


lf!< 

'%. 

. 

•/ 

'( i\ 

^  n 

/ 

\ 

\ 

^ 

Fig.  617. — Suturing  extensor  tendons 
to  skin  flap.      (T'eaw.) 


Fig.  6x8. — Suture  and  drainage.       (Ffaw.) 


shape  the  long  palmar  flap  by  transfixion  and  cutting  outward,  or  by 
cutting  from  without  inward  (Fig.  617). 

Suture  the  tendons  to  the  periosteum  or  fibrous  tissues,  for  if  the 
tendo-achilles  is  left  unopposed  the  result  will  be  a  useless  stump. 
Resect  the  nerves  and  suture,  using  drainage  (Fig.  618). 


AMPUTATION    OF   FOOT  767 

TOTAL  AMPUTATION  OF  THE  FOOT 

In  total  amputation  of  the  foot,  the  exact  procedure  will  depend 
chiefly  upon  the  condition  of  the  os  calcis.  If  it  is  sound,  Pirogoff's 
osteoplastic  amputation  is  indicated.  If  the  os  calcis  is  diseased, 
Symes'  amputation  is  indicated — 3,  disarticulation  at  the  ankle-joint, 
with  erasion  of  the  malleoli.  But  one  cannot  always  determine  be- 
forehand the  state  of  the  os  calcis,  and  therefore  an  incision  should  be 
made  which  will  permit  either  procedure  after  the  os  calcis  has 
been  examined. 

First  hicision. — The  first  incision  extends  across  the  sole  with  one 
end  at  the  tip  of  the  external  malleolus  and  the  other  a  finger's 


Fig.  619. — Line  of  incision  for  complete  amputation  of  foot.     {Veau.) 

breadth  below  the  tip  of  the  internal  malleolus.  (The  internal  mal- 
leolus does  not  extend  quite  so  low  as  the  external)  (Fig.  619). 

An  assistant  elevates  the  limb;  you  seize  the  foot  with  the  left  hand 
and  make  this  plantar  incision  from  left  to  right;  that  is  to  say,  in  the 
case  of  the  right  foot  begin  the  incision  at  the  end  of  the  outer  malleo- 
lus and  terminate  it  a  finger's  breadth  below  the  internal.  In  the 
case  of  the  left  foot,  begin  at  the  internal  and  end  at  the  external 
malleolus. 

Repeat  the  movement  several  times,  for  there  is  always  consider- 
able difiiculty  in  accomplishing  complete  section  of  the  tendons,  some 
of  which  are  oblique  to  the  line  of  incision  and  others  deep  and  im- 
bedded in  grooves. 

Second  Incision. — -Connect  the  extremities  of  the  first  incision  by  a 


768 


SOME  PRACTICAL  AMPUTATIONS 


dorsal  incision,  which  should  be  slightly  convex  forward  toward  the 
toes.  This  line  crosses  over  the  head  of  the  astragalus.  The  foot 
should  be  lowered  and  the  cut  made  from  left  to  right.  Extension 
of  the  foot  will  facilitate  the  division  of  the  anterior  tendons  and 
ligaments. 

Now  distinguish  the  head  of  the  astralagus,  and  between  it  and  the 
articular  surface  of  the  malleolus  pass  the  point  of  the  knife  and  cut 


Fig.  620. — Section  of  the  lateral  ligaments. 
{Veau.) 


Fig.  621. — Clearing  the  upper  and  internal 
surfaces  of  the  os  calcis.     (^Veau.) 


downward  (Fig.   620).     By  this  means,  the  lateral  ligaments  are 
divided. 

The  posterior  ligaments  are  divided  by  cutting  along  the  upper 
surface  of  the  os  calcis  (Fig.  621).  The  joint  is  now  freely  exposed 
and  the  os  calcis  may  be  brought  into  view  and  examined.  In  exam- 
ining the  outer  side,  dissect  back  the  soft  parts  for  an  inch,  but  not 
quite  so  far  on  the  inner  side.  To  be  sure  of  the  condition  of  the  bone, 
its  substance  must  be  inspected. 


AMPUTATION   OF   FOOT  769 

(A)  Suppose  tJic  Os  Calcis  is  Sound. — ^Grasp  the  foot  firmly  with 
the  left  hand,  depress  it  and  pull  upon  it  at  the  same  time,  while  the 
assistant  retracts  the  flaps,  which  have  been  loosed  from  the  sides  of 
the  bone. 

The  flaps  are  held  back  by  retractors  on  each  side,  which  are 
slipped  down  with  the  progress  of  the  saw,  the  assistant  bracing  his 
thumbs  against  the  heel. 

The  saw  is  started  in  the  upper  face  of  the  os  calcis,  a  finger's 
breadth  behind  the  astragalus  in  a  manner  to  take  off  a  slice  from 
above  downward  and  forward  (Fig.  622).     With  the  completion  of 


Fig.  622. — Section  of  the  os  calcis.     The  saw  directed  downward  and  forward.     The  re- 
tractors slipped  downward  as  the  saw  progresses.     {Faraheuf.) 


this  section,  the  foot  is  removed,  and  the  posterior  part  of  the  divided 
OS  calcis  is  left  in  the  heel  flap. 

The  next  step  is  to  saw  of  the  malleoli.  Begin  by  completely  de- 
nuding these  processes  of  their  covering,  skin,  fascia  and  tendons. 
C^rry  the  denudation  upward,  a  distance  of  two  fingers'  breadth  be- 
hind; just  above  the  level  of  the  articular  surface  of  the  tibia,  in  front. 
The  posterior  tendons  especially  are  sometimes  difficult  to  dislodge 
from  their  groove. 

The  line  of  section  being  thus  cleared,  the  heel  flap  is  held  well  up 
toward  the  calf,  out  of  the  way,  by  the  assistant,  who  also  supports 
the  leg  in  the  horizontal  position. 

It  is  well  for  the  operator  to  steady  the  limb  by  seizing  one  of  the 

malleoli  with  a  bone-holding  forceps.     The  saw  enters  just  above  the 

articular  line  in  front,  and  emerges  a  full  finger's  breadth  above  that 

level  (Fig.  623).     If  the  section  is  not  carefully  made,  the  coapta- 

49 


770 


SOME   PRACTICAL   AMPUTATIONS 


tion  of  the  sawed  surface  of  the  os  calcis  to  that  of  the  tibia  may 
be  imperfect. 

Complete  the  hemostasis,  bring  the  two  bone  surfaces  together,  and 
suture  the  anterior  tendons  to  the  fibrous  covering  of  the  under  sur- 
face of  the  OS  calcis,  the  better  to  fix  this  stump  in  position.  If  it  is 
feared  the  bone  will  slip,  one  or  two  bone  sutures  may  be  employed. 
Suture  the  skin,  usually  employing  drainage. 

(B)  Suppose  the  Os  Calcis  is  Diseased. — In  case  the  os  calcis  is  dis- 
eased, it  must  be  entirely  removed,  instead  of  sawed. 


Fig.  623. — Parts  removed  in  Pirogoflf's  amputation  represented  in  dark,     {yeau.) 

The  left  hand  strongly  flexes  the  foot,  until  the  posterior  end  of  the 
OS  calcis  points  upward  (Fig.  624),  and  as  the  point  of  the  knife  dis- 
sects the  tissues  off  the  left  side,  the  foot  is  rotated  to  the  right,  and 
when  working  on  the  right  side,  rotated  to  the  left;  in  this  manner  the 
OS  calcis  is  finally  enucleated,  being  careful  to  follow  the  bone  closely 
and  not  to  "button-hole"  the  flap. 

Remember  the  principal  vessels  are  to  the  inner  side  and  are  to  be 
lifted  up  with  the  flap. 

Especial  care  is  required  when  the  attachment  of  the  tendo-achilles 
is  divided;  the  bone  must  be  shaved,  for  it  is  here  practically  sub- 


AMPUTATION   OF   FOOT 


771 


Fig.  624. — Denudation  of  the  posterior  surface  of  the  os  calcis.     {Farabeuf.) 


Fig.  625. — Syme's  amputation  of  the  foot.     {Farabeuf.) 


772 


SOME   PRACTICAL  AMPUTATIONS 


cutaneous,  and  it  is  easy  to  puncture  the  flap.  You  may  expect 
this  stage  to  be  tedious. 

Finally  the  foot  will  be  removed  (Fig.  625). 

Now  denude  the  lower  end  of  the  bones  of  the  leg,  observing  that 
the  tendons  in  front  are  held  down  by  their  fibrous  sheaths.  In 
order  to  facilitate  this  dissection,  sweep  the  point  of  the  knife  around 
the  bone,  keeping  it  in  close  contact  with  the  bone.     This  dissection 


Fig.  626. — Suture  and  drainage.     (Veau.) 

must  be  carried  upward  for  an  inch  and  the  malleoli  will  be  com- 
pletely exposed. 

Steady  the  leg  with  a  bone-holding  forceps,  and  saw  the  bones  at 
the  level  of  the  cartilage.  Begin  by  notching  the  tibia,  then  com- 
plete the  section  of  the  external  malleolus  and  terminate  with  the 
section  of  the  tibia.     If  some  cartilage  remains,  it  may  be  scraped  off. 

Resect  the  nerves,  suture  and  drain  (Fig.  626). 

AMPUTATION  OF  THE  LEG 

The  leg  may  be  amputated  at  any  level.  Formerly,  when  sup- 
puration was  the  rule,  and  the  cicatrix  was  large,  adherent,  and  pain- 


AMPUTATION   OF    LEG 


773 


ful,  prohibiting  the  use  of  artificial  limbs,  the  "point  of  election" 
was  high  up.  The  knee  was  flexed  and  the  patient  made  use  of  a 
''peg-leg,"  the  weight  falHng  on  the  patella  (Fig.  627). 

With  present  methods  the  scar  is  a  matter  of  less  concern  and  the 
aim  should  be  to  amputate  as  low  down  as  possible,  to  the  end  that 


Fig.  627. — Knee  flexed  for 
"peg-leg."     (Veau.) 


Fig.  628. — Artificial  limb       FiG.     629. — Amputation  of 
applied.      ^Veau.)  leg.     Lines  of  section  of  soft 

parts  and  bone.      (Veau.) 


the  muscles  may  be  preserved  to  render  efiicient  an  artificial  Hmb 
(Fig.  628). 

This  principle  is  true  only  within  certain  limits.  Amputations 
just  above  the  ankle  never  furnish  a  good  stump  for  an  artificiaUimb. 
It  is  better  to  amputate  at  the  junction  of  the  middle  and  lower  thirds. 


774 


SOME   PRACTICAL   AMPUTATIONS 


In  the  case  of  traumatism  and  gangrene,  then,  do  an  atypical 
amputation,  preserving  carefully  the  sound  tissue  and  dividing  the 
bone  to  accommodate  the  skin  flap. 

If  the  bone  is  involved  to  a  greater  extent  than  the  skin,  as  in 
tuberculosis,  a  typical  amputation  may  be  done.  If  the  stump  be- 
low the  knee  is  4  inches  long  it  can  manage  an  artificial  limb. 


Fig.  633. — Loosening  the  attachments  of 
the  flap  to  the  tibia.     (Veau.) 


Fig.  634. — Dissecting  up  the  muscles 
with  the  artery.     {Veau.) 


There  are  numerous  methods  of  amputating  the  leg,  some  appro- 
priate to  one  level  and  some  to  another,  but  for  the  sake  of  simplicity 
but  one  need  be  described — one  which  may  be  used  with  fair  success 
in  any  part  of  the  leg.  In  any  case  avoid  redundancy  of  flap  if  an 
artificial  leg  is  to  be  worn. 

Incision. — Begin  with  a  circular  incision  of  the  skin  about  2>2 
inches  below  the  level  of  the  proposed  bone  section  (Fig.  629).  This 
incision  will  divide  the  skin  and  aponeurosis.     If  front,   carefully 


AMPUTATION   OF   LEG 


775 


separate  the  skin  from  the  tibial  crest  (Fig.  630).  Next  divide  the 
muscles  at  the  level  of  the  retracted  skin.  Divide  the  muscles 
completely,  but  make  the  incision  oblique  to  the  axis  of  the  limb,  so 
that  the  incision  reaches  the  bone  at  a  higher  level  than  at  the  sur- 
face (Fig.  631). 

To  be  certain  that  all  the  muscles  are  divided,  one  may  re-pass  the 
bistoury,  as  in  the  forearm  (Fig.  596).  Next  denude  the  bones  with 
the  rugine,  reaching  above  the  level  at  which  the  bones  are  to  be 
sawed.  This  denudation  is  most  difficult  and 
tedious  behind,  on  account  of  the  fibrous  at- 
tachments of  various  muscles. 

The  interosseous  membrane  is  to  be  detached 
by  a  few  vigorous  strokes  with  the  rugine  from 
below  upward.  Divide  it  at  the  level  of  the 
proposed  bone  section. 

Retract  the  flaps  with  three  gauze  compresses, 
one  passed  between  the  bones,  one  applied  in 
front  and  one  behind;  all  to  be  held  firmly  by 
the  assistant. 

Begin  the  sawing  by  notching  the  tibia,  then 
completely  divide  the  fibula  and  end  with  the 
section  of  the  tibia.     Plane  off  the  projecting 
angle  of  the  anterior  border  of  the  tibia,  resect  the  nerves  and  ligate 
the  bleeding  points.     Be  sure  the  fibula  is  not  left  longer  than  the 
tibia  to  interfere  with  an  artificial  limb.     Drain,  suture  the  anterior 
muscular  flap  to  the  posterior,  and  suture  the  skin  (Fig.  632). 


Fig.  635. — Amputa- 
tion complete.  Trans- 
verse drainage.    {Veau.) 


AMPUTATION  THROUGH  THE  KNEE-JOINT 

This  operation  should  be  done  in  preference  to  an  amputation  of 
the  thigh. 

''The  femoral  artery  having  been  controlled,  the  limb  supported 
over  the  edge  of  the  table  and  slightly  flexed,  the  surgeon  standing  on 
the  right  side  of  either  limb,  marks  out  two  broad  lateral  flaps  as 
follows :  his  left  thumb  and  index  finger  being  placed,  the  former  over 
the  center  of  the  head  of  the  tibia,  the  latter  at  the  corresponding 
point  behind,  opposite  the  center  of  the  joint,  he  marks  out  (in  the 


776 


SOME   PRACTICAL   AMPUTATIONS 


case  of  the  right  Umb)  an  inner  flap  by  an  incision  which  commences 
behind  at  the  index  finger  and  runs  down  the  back  of  the  leg  for  33^ 
inches,  and  then  curves  up  to  the  thumb.  A  similar  flap  is  shaped 
on  the  outer  side. 

"The  inner  flap  must  be  sHghtly  larger,  in  view  of  the  large  side  of 
the  inner  condyles. 

"  The  flaps  consist  of  skin  and  fascia.  When  they  have  been  raised 
to  the  level  of  the  articulation,  the  ligamentum  patellae  is  severed. 


/■ 


/ 


Fig.  633. — Amputation  of  thigh.     Circular  incision  of  the  skin. 


allowing  the  patella  to  go  upward.  The  soft  parts  around  the  joint 
are  then  cut  through  with  a  circular  sweep  and  the  leg  removed.  In 
doing  this,  the  hmb  being  flexed  to  relax  the  parts  and  faciUtate 
opening  the  joint,  the  semicircular  cartilages  will  very  likely  be  found 
encircling  the  condyles  of  the  femur  and  are  to  be  left  in  situ  by 
dividing  the  coronary  ligaments  which  tie  them  to  the  tibia.  The 
condyles  should  always  be  saved  if  possible  for  they  favor  the  useful- 
ness of  an  artificial  limb.  Resect  the  nerves,  Hgate  the  vessels, 
drain  and  suture,"     (Jacobson's  Operative  Surgery.) 


AMPUTATION   OF   THIGH 


777 


AMPUTATION  OF  THE  THIGH 

Determine  the  level  of  the  bone  section.  About  the  distance  of  one 
diameter  of  the  limb  below  this  level,  describe  a  circular  incision, 
dividing  the  skin  and  fascia,  which  may  descend  a  little  further  be- 
hind than  in  front,  if  desired. 

The  patient's  legs  are  drawn  out  well  over  the  edge  of  the  table,  the 
sound  limb  flexed  and  the  injured  one  held  by  an  assistant.     The 


Fig.  634. — Amputation  of  thigh.     Loosening  the  flap  after  a  circular  skin  section. 

operator  stands  to  the  outside.  Another  assistant  encircles  the  thigh 
above  the  level  of  the  incision,  with  his  hands.  If  the  conventional 
amputating  knife  is  used,  begin  (on  the  right  thigh)  by  passing  the 
knife  under  the  limb  and  with  its  heel  resting  upon  the  upper  surface, 
bring  it  in  a  circular  sweep  back  around  the  thigh,  dividing  succes- 
sively the  integument  of  the  internal,  inferior  and  external  surfaces. 
The  position  of  the  hand  may  be  slightly  changed  and  the  incision 
continued  up  over  the  anterior  surface;  or  that  may  be  divided  by  a 
second  movement  (Fig.  633). 

In  the  meantime,  the  left  hand  has  steadied  the  skin;  the  assistant 
now  retracts  it  while  its  fibrous  attachments  are  loosened  (Fig.  634) 
until  there  is  a  separation  of  at  least  three  fingers'  breadth.     At  the 


778 


SOME  PRACTICAL  AMPUTATIONS 


level  of  the  retracted  skin,  divide  the  muscles  as  the  skin  was  divided, 
aiming  to  reach  the  bone.  But  the  divided  muscles  do  not  equally 
retract,  and  a  second  circular  incision  of  the  muscles  at  the  level  of  the 
retracted  skin  is  necessary  to  insure  a  uniform  stump  (Fig.  638). 

Denude  the  femur  beyond  the  level  of  the  proposed  bone  section. 
Direct  the  assistant  to  retract  the  flap  with  two  lateral  compresses  or 
retractors. 


Fig.  635. — Amputation  of  thigh.     Circular  section  of  the  mviscles  after  retraction  of  skin. 

Saw  the  femur,  ligate  all  vessels  hkely  to  bleed,  suture  the  muscles 
over  the  end  of  the  femur,  drain,  and  suture  the  skin. 


AMPUTATION  OF  THE  HIP-JOINT 

"Primary  amputation  of  the  hip  comes  under  consideration  in  any 
extensive  crush  of  the  thigh  or  gunshot  injury,  but  offers  hardly  any 
chance  while  the  primary  shock  exists. 

"The  better  plan  is  to  try  and  check  the  hemorrhage,  clean  the 
wound  as  much  as  possible,  pack  -with  gauze  and  wait.  The  patient 
having  rallied  from  the  shock,  and  gangrene,  sloughing  and  necrosis 


AMPUTATION   inP-JOINT  779 

being  imminent,  amputation  is  indicated  with  a  fair  prospect  of  sav- 
ing life,*  *  *  The  hrst  step  is  to  control  hemorrhage.  *  *  *  But  there 
is  one  method  safe  and  applicable  to  all  cases  and  especially  when  the 
surgeon  is  unaccustomed  to  the  operation,  and  that  is  to  divide  the 
common  femoral  vein  and  artery,  each  between  two  ligatures.  There 
is  then  no  further  bleeding,  except  from  the  region  of  the  crucial 
anastomosis  behind,  the  vessels  forming  which  are  easily  picked  up 
and  divided." 

Formation  of  the  Flaps. — "From  the  lower  end  of  the  longitudinal 
incision  for  tying  the  vessels,  a  circular  incision  is  continued  around 
the  thigh,  the  skin  flaps  retracted  and  the  soft  parts  divided  as  ampu- 
tation of  the  thigh."     (Walsham's  Surgery.) 

Sennas  Bloodless  Amputation  at  the  Hip-joint. — First  incision:  with 
the  pelvis  resting  on  the  lower  edge  of  the  table,  make  a  straight  in- 
cision (beginning  about  3  inches  above  the  great  trochanter)  about 
8  inches  in  length,  directly  over  the  center  of  the  great  trochanter, 
and  parallel  to  the  long  axis  of  the  limb.  When  the  knife  reaches  the 
great  trochanter,  its  point  should  be  kept  in  contact  with  the  bone 
the  whole  length  of  the  remaining  part  of  the  incision. 

The  margins  of  the  wound  are  now  retracted  and  any  spurting  ves- 
sels secured. 

The  trochanteric  muscular  attachments  are  now  severed  close  to 
the  bone  with  a  stout  scalpel.  The  cleaning  of  the  digital  fossa  and 
the  division  of  the  obturator  externus  tendon,  require  special  care. 
The  thigh  is  now  flexed,  strongly  abducted,  rotated  inward,  when 
the  capsular  ligament  is  divided  transversely  at  its  upper  and  poste- 
rior aspect.  The  remaining  portion  of  the  capsular  ligament  is  sev- 
ered, while  the  thigh  is  brought  back  to  a  position  of  shght  flexion, 
after  which  it  is  rotated  outward  and,  if  possible,  the  ligamentum  teres 
is  cut.  If  this  cannot  be  done,  the  head  of  the  bone  is  forcibly  dis- 
located upon  the  dorsum  of  the  ilium  by  flexion,  adduction  and  rota- 
tion of  the  thigh. 

The  trochanter  minor  and  upper  part  of  the  shaft  of  the  femur  are 
cleared  by  using  a  scalpel  and  periosteal  elevator  alternately.  At 
the  completion  of  this  part  of  the  operation,  the  femur  is  in  a  position 
of  extreme  adduction  and  the  upper  portion  projects  some  distance 
from  the  wound. 


7  So  SOME    PRACTICAL   AMPUTATIONS 

If  the  surgeon  has  kept  in  close  contact  with  the  bone  and  has  used 
the  knife  sparingly  and  the  periosteal  elevator  freely,  the  hemorrhage 
has  been  slight. 

Elastic  constriction  is  now  applied.  Bring  the  limb  down  in  a 
straight  line  with  the  body.  A  long  straight  hemostatic  forceps  is 
inserted  into  the  wound  behind  the  femur  and  on  a  level  with  the 
trochanter  minor  when  in  a  normal  position.  The  instrument  is 
then  pushed  inward  and  downward  2  inches  below  the  ramus  of  the 
ischium  and  just  behind  the  adductor  muscles.     As  soon  as  the  point 


Fig.  636. — Amputation  at  hip-joint.  Elastic  constriction  completed  by  constricting  the 
posterior  segment  of  the  thigh.  Flaps  formed,  including  all  the  tissues  down  to  the  muscles. 
{Senn.) 

can  be  felt  under  the  skin  in  this  location,  2-inch  incision  is  made 
through  the  skin,  through  which  the  instrument  is  made  to  emerge. 

After  enlarging  the  tunnel  made  in  the  soft  tissues  by  dilating  the 
branches  of  the  forceps,  a  piece  of  aseptic  rubber  tubing,  3  or 
4  feet  in  length,  is  grasped  in  the  middle  with  the  forceps  and 
drawn  along  the  tunnel  as  the  forceps  are  withdraw^n,  whereupon  the 
rubber  tube  is  cut  in  two  where  it  w^as  held  by  the  forceps. 

With  one-half  of  the  tube,  the  anterior  segment  of  the  thigh  is 
constricted  sufficiently  firmly  to  intercept  both  the  arterial  and  ven- 
ous circulation  completely. 


AMPUTATION   JUP-JOINT 


781 


Before  the  constrictor  is  tied,  the  Hmb  should  be  held  in  the  vertical 
position  long  enough  to  render  it  practically  bloodless.  The  elastic 
constrictor  is  either  tied  or,  still  better,  held  with  a  forceps  at  the 
point  of  crossing. 


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/': 

1 

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tc^ 

/         y 

r 

/  ^ 

wf^^ 

\x 

/       / 

^\ 

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// 

^i^^^^^k 

w 

> 

PP^^^^^T^c^"^  "^ 

r  f 

^ 

I 

m 

A 

\ 

\ 

Fig.  637. — Senn's  method  of  performing  bloodless  amputation  at  the  hip-joint.  Dislo- 
cation of  head  of  femur  an_i  upper  portion  of  shaft  through  straight  external  incision. 
Elastic  constrictors  in  place;  the  anterior  one  tied. 


The  posterior  segment  of  the  thigh  is  constricted  by  the  remaining 
half  of  the  tube,  which  is  drawn  sufficiently  tight  behind;  the  ends  of 
the  tube  are  made  to  cross  each  other  and  are  brought  forward  and 
made  to  include  the  anterior  segment,  when  they  are  again  firmly 
drawn  and  tied,  or  otherwise  fastened  above  the  first  constrictor, 


782  SOME   PRACTICAL  AMPUTATIONS 

furnishing  an  additional  security  against  hemorrhage  from  the  larger 
vessels  in  the  anterior  flap,  when  cut  during  the  amputation 
(Fig.  636). 

After  the  principal  blood  vessels  have  been  tied,  the  posterior  con- 
strictor is  removed  and  additional  bleeding  points  are  secured  before 
the  anterior  constrictor  is  removed  (Fig.  637). 

Surface  compression  with  a  compress  wrung  out  of  hot,  normal 
salt  solution,  is  a  valuable  aid  in  minimizing  the  hemorrhage,  after 
the  removal  of  the  constrictors. 

"As  this  method  of  controlling  hemorrhage  does  not  require  the 
presence  of  a  skilled  assistant,  it  will  prove  of  especial  value  in  emer- 
gency cases.  The  operation  can  be  performed  with  the  instruments 
contained  in  every  pocket  case.  Should  an  elastic  tube  not  be  at 
hand,  the  constriction  can  be  made  in  a  satisfactory  manner  by  sub- 
stituting a  cord  made  of  sterile  gauze,  tightened  with  a  lever  of  some 
kind,  as  is  done  in  applying  the  ordinary  Spanish  windlass."  (Senn, 
Practical  Surgery.) 

The  amputation  is  completed  by  cutting  antero-posterior  flaps  as 
shown  in  Fig.  636. 


CHAPTER  XXIII 

DILATATION  OF  THE  SPHINCTER  ANI;  OPERATION  FOR 
PILES ;  OPERATION  FOR  FISTULA 

DILATATION 

Temporary  paralysis  of  the  anal  sphincter  is  the  preliminary  step 
to  most  of  the  interventions  on  the  rectum,  and  is  of  itself  usually 
sufficient  for  the  cure  of  fissures. 

The  patient  should  be  purged  the  day  preceding  the  operation 


Fig.  638. — Dilatation  of  the  rectum.     (Veau.) 

and  the  rectum  should  be  washed  out  with  soap  and  water,  prelim- 
inary to  the  actual  operation. 

General  anesthesia  is  almost  indispensable  and  it  needs  to  be  pro- 
found, for  the  anal  reflex  is  one  of  the  last  to  yield.  Spinal  anes- 
thesia is  often  useful  in  anal  operations. 

783 


784 


DILATATION    OF   THE    SPHINCTER    ANI 


In  the  absence  of  a  special  dilator,  begin  by  inserting  the  two 
thumbs  back  to  back,  and  bracing  the  fingers  against  the  outer  sur- 
face of  the  hips,  stretching  the  sphincter  by  rhythmic  movements  of 
the  thumbs,  gradually  increasing  the  force.  There  is  no  danger  of 
overdilatation,  so  continue  until  the  thumbs  are  in  contact  with  the 
ischial  tuberosities  (Fig.  638).  Drainage  is  indicated  in  simple 
dilatation  for  fissure. 


Fig.  639. — Drainage  after  dilatation.     (Veau.) 

Employ  either  one  large  or  two  or  three  small  tubes  wtU  wrapped 
with  iodoform  gauze  soaked  in  cocainized  vaseline  (vasehne  thirty 
parts,  cocaine  one  part),  in  order  that  the  subsequent  pain  may  not 
be  so  severe  (Fig.  639).  The  tubes  may  be  removed  on  the  second 
day  and  the  bowels  moved  on  the  third. 

OPERATION  FOR  HEMORRHOIDS 


Most  cases  of  piles  are  curable  by  local  and  constitutional  treat- 
ment; however,  those  that  are  very  large,  bleeding  and  inflamed, 
require  an  operation  for  their  removal  and  radical  cure. 

There   are   several   methods    of  procedure,    many  of  which  are 


OPERATION   FOR   PILES 


7«5 


successful,  none  dangerous  and  quite  within  the  scope  of  every 
practitioner. 

The  following  may  be  recommended  in  those  cases  in  which  the 
marginal  tumors  are  well  defined  but  not  pedunculated: 

Begin  by  a  careful  cleansing  of  the  bowel  by  purgation  and  lavage. 
Three  days  before  the  operation,  give  a  free  purge  and  prescribe  a 
liquid  diet.  Prescribe  an  enema  each  morning  and  evening  for  the 
next  two  days.  On  the  day  preceding  the  operation,  it  is  a  good  idea 
to  check  peristalsis  with  a  small  dose  of  opium. 


Fig.  640. — Making  the  first  incision.   {Veau.)     Fig.  641. — Passing  the  first  suture.   (Veau. 


Employ  general  anesthesia.  Carefully  cleanse  the  peri-anal  region 
and  scrub  the  rectum  with  soap  and  water.  Dilate  the  anus,  as  pre- 
viously described;  and  when  the  dilatation  is  complete  the  anal  orifice 
will  be  everted  more  or  less,  presenting  a  ring  of  pile  tumors.  Fasten 
the  pile  tumor  with  a  forceps,  and  at  its  lower  end,  make  a  short 
curved  incision  (Fig.  640).  The  incision  involves  only  the  skin, 
which  is  to  be  loosened  from  the  underlying  structures  by  a  little 
blunt  dissection.  Suture  this  part  of  the  skin  before  proceeding 
further,  using  a  small  curved  needle  armed  with  a  No.  2  catgut. 
Tie  the  suture  moderately  tight  and  leave  the  threads  long  for  a 
so 


786 


DILATATION    OF   THE    SPHINCTER   ANI 


landmark,  which  will  be  appreciated  later  on.  Pass  two  or  three 
sutures  in  this  manner,  depending  upon  the  length  of  the  incision 
(Fig.  641). 


-;   -^ 


Fig.  642. — Freeing  the   veins   by   blunt 
dissection.     {Veau.) 


Fig.  643. — Ligation    of    the    first    vascular 
pedicle.     {Veau.) 


Fig.  644. — Burying   the   pedicle   by 
suture.     {Veau.) 


Fig.  645. — Ligation   of   the   last    vascular 
pedicle.     {Veau.) 


Again  prolong  the  incision  on  either  side  a  Httle  way  and  detach, 
by  blunt  dissection,  the  lips  of  the  wound  from  the  veins  beneath,  by 
which  means  a  sort  of  pedicle  is  formed  (Fig.  642).  This  pedicle 
consists  of  a  part  of  the  veins  which  are  to  be  ligated  and  excised. 


OPERATION  FOR  PILES 


787 


Pass  a  ligature  around  a  part  of  the  veins  (Fig.  643)  and  tie.  Di- 
vide the  ligated  veins  to  the  outer  side  and  cut  the  ligatures  short. 

Now  pass  a  suture  so  as  to  enclose  and  cover  in  the  stump 
(Fig.  644). 

Again  prolong  the  original  incision  on  each  side  of  the  base  of  the 
tumor  and  expose  more  of  the  pedicle;  ligate,  excise  and  suture  as  be- 
fore, until  finally  the  upper  pole  of  the  tumor  is  reached,  and  the  last 
of  the  pedicle  tied  off  (Fig.  645). 

The  terminal  sutures  enclose  the  last  stump  of  the  pedicle  and  com- 
plete the  repair  of  the  incision  at  the  same  time  (Fig.  649). 


Fig.  646. — Applying  the  last  suture.    {Veau.) 


Fig,  647. — Treatment    of    ulcerated 
piles  by  cautery.     {Veau.) 


It  is  better  to  proceed  thus  from  below  upward  in  order  that  the 
blood,  always  considerable,  will  flow  downward  and  mask  only  the 
field  already  sutured. 

The  line  of  incision  must  follow  closely  the  base  of  the  tumor,  for 
if  the  edges  of  the  wound  are  too  widely  separated,  the  strain  may 
cause  the  sutures  to  tear  out. 

If  the  whole  of  the  anal  circumference  is  involved,  it  is  necessary  to 
treat  in  the  manner  described  the  two  sides  only. 

Do  not  disturb  the  anterior  and  posterior  poles  of  the  anal  border, 
although,  if  necessary,  those  points  may  be  touched  up  with  the 
thermo-cautery. 

Place  drainage-tubes  wrapped  with  iodoform  gauze  saturated  in 
vaseHne,  as  described  under  the  head  of  Dilatation  of  the  Sphincter. 


788 


DILATATION    OF   THE    SPHINCTER   ANT 


The  subsequent  pain  is  always  severe  and  will  require  a  hypoder- 
mic injection  of  morphine.  Retention  of  urine  is  often  present. 
The  external  dressings  should  be  changed  daily  and  liquid  diet  main- 
tained for  five  or  six  days  and  the  bowels  kept  under  restraint.  Do 
not  be  concerned  with  the  swelling. 

On  the  sixth  day,  remove  the  drainage-tube;  on  the  seventh,  open 
the  bowels  with  castor  oil  or  compound  licorice  powder,  one  heaping 


Fig.  648. — ^Laying  open  the  track  of  fistxola  on  the  grooved  director.     {Veau.) 

teaspoonful  every  four  hours  till  the  bowels  move,  and  instruct  the 
patient  to  cleanse  carefully  the  anal  region  after  each  movement. 

The  sutures  wdll  be  absorbed  and  if  none  give  way  too  soon,  the 
healing  will  be  complete  in  about  two  weeks;  otherwise  there  may  be 
a  raw  surface  which  will  need  to  be  dressed  a  little  longer. 

In  certain  cases  there  is  no  w^ell-defined  tumor,  but  the  surface  is 
ulcerated,  infected  and  exceedingly  painful,  and  is  unaffected  by  pa- 
tient local  treatment. 

In  such  a  case,  the  thermo-cautery  will  probably  give  the  best  re- 
sults. For  one  or  two  days  the  patient  is  kept  in  bed  and  a  moist 
dressing  applied  which  will  diminish  the  swelling. 

Employ  general  anesthesia,  cleanse  and  dilate  the  anus.     The 


OPERATION   FOR   PILES  789 

thermo-cautery  is  heated  to  a  dull  red.  Pressed  into  the  tumor,  it 
loses  its  glow  (Fig.  647).  Reheat  it  and  reapply  a  short  distance 
from  the  point  of  application,  and  in  this  manner  proceed  until  the 
pile  has  been  well  punctured.  It  is  not  necessary  to  puncture  deeply. 
Apply  drainage  and  a  moist  dressing.  The  subsequent  pain  is  al- 
ways severe  and  must  be  controlled  by  a  h}'podermic  of  morphine. 
There  may  be  retention  of  urine  requiring  relief  by  catheterization. 


Fig.  649, — Cauterization  of  the  diverticula  of  the  fistula.     {Veati.) 

The  dressing  must  be  renewed  twice  daily.  The  eschar  will  drop  off 
between  the  fourth  and  eighth  day,  and  the  bowels  should  be  moved 
about  the  eighth  day.     The  cure  will  be  complete  in  about  a  month. 

OPERATION   FOR   ANAL   FISTULA 

A  grooved  director  is  passed  through  the  fistulous  tract  and  emerg- 
ing in  the  rectum,  its  point  is  caught  by  the  finger  in  the  rectum  and 
brought  outside  the  anus.  The  whole  length  of  the  tract  is  laid  open 
(Fig.  648). 

The  diseased  tissues  are  then  curetted  or  touched  with  the  cautery 
(Fig.  649).     Pack  with  gauze  until  repair  by  granulation  is  complete. 


CHAPTER  XXIV 

PHIMOSIS;  PARAPHIMOSIS;  CIRCUMCISION; 
HYDROCELE;  CASTRATION 

PHIMOSIS 

Phimosis  may  be  congenital  or  acquired,  though  it  is  much  more 
frequently  the  former.  There  is  usually  present  one  or  both  of  two 
conditions:  a  redundant  prepuce  with  contracted  orifice;  or  a  frenum 
so  short  as  not  to  permit  retraction  without  marked  bowing  of  the 
organ. 

The  disturbances  produced  by  congenital  phimosis  are  due  either 
to  mechanical  interference  or  reflex  irritability,  although,  of  course, 
many  cases  of  phimosis  seem  to  give  rise  to  the  symptoms.  The 
mechanical  interference  may  lead  to  infection,  balanitis,  or  even  ure- 
thritis, or  to  straining  which  may  be  the  origin  of  an  inguinal  or 
umbiHcal  hernia;  the  straining  may  also  produce  prolapsus  ani  or 
hydrocele  by  pressure  on  the  spermatic  vessels. 

The  reflex  symptoms,  often  due  perhaps  to  the  adhesions  of  the 
prepuce  to  the  glans,  are  numerous  and  varied,  the  most  common  be- 
ing disturbances  of  micturition,  erethrism,  and  functional  nervous 
derangements. 

Every  case  of  phimosis,  therefore,  should  receive  attention  in  in- 
fancy, and  in  general  the  only  treatment  worth  while  is  circumcision. 

The  acquired  phimosis  of  adult  life,  most  often  due  to  acute  in- 
fective inflammations,  is  usually  to  be  relieved  by  antiseptic  washes 
and  treatment  addressed  to  the  septic  cause. 

PARAPHIMOSIS 

Paraphimosis  has  its  origin  in  certain  malformations,  traumatism, 
or  inflammations,  and  appears  in  many  degrees  of  severity.  In  some 
causes  it  is  easily  reduced;  in  others,  irreducible  without  an  operation. 
There  is  always  the  danger,  in  severe  and  neglected  cases,  of  ulcera- 

790 


PARAPHIMOSIS 


791 


tion^  sloughing,  or  gangrene.  The  appearances  are  more  or  less  con- 
stant: the  exposed  glans  is  swollen  and  reddened;  behind  it  is  a  collar 
of  congested  mucous  membrane;  behind  this  a  deep  furrow  in  which 
lies  the  constricting  band;  and  behind  this,  another  band  of  swollen 
integument. 

An  effort  must  be  made  at  once  to  reduce  the  foreskin. .  The  re- 
duction is  always  painful.  Begin  by  thoro ughly  cleansing  and  cocain- 
izing the  parts.  Apply  a  compress  saturated  with  a  20  per  cent, 
solution  of  cocaine  and  then  wait  ten  minutes. 

Smear  a  little  vaseline  on  the  balano-preputial  furrow,  but  not  over 
the  glans  generally,  else  the  manipulating  fingers  will  slip. 


Fig.  650. — Reducing  a  paraphimosis.     (Stewart.) 

The  purpose  is  to  apply  a  slow,  firm,  and  progressive  pressure  to  the 
engorged  tissues,  at  the  same  time  making  traction  forward  on  the 
foreskin  and  pressure  backward  on  the  glans. 

There  are  several  ways  of  doing  this,  of  which  the  following  is  an 
excellent  method:  grasp  the  penis  behind  the  glans,  between  the  first 
and  second  fingers  of  each  hand,  and  while  these- make  compression 
and  traction,  the  two  thumbs  are  braced  against  the  apex  of  the  glans 
(Fig.  650). 

After  reduction  is  accomplished,  measures  must  be  employed  to 
subdue  the  inflammation  and  the  patient  advised  of  the  necessity  for 
a  circumcision  later  to  insure  against  a  recurrence. 

If  reduction  cannot  be  accomplished  by  these  measures,  an  opera- 
tion must  be  done  without  delay.  The  purpose  is  to  divide  the  re- 
stricting band,  which  lies  in  the  groove  between  the  two  ridges. 


792  CIRCUMCISION 

Inject  a  little  cocaine  along  the  line  of  incision  which  is  usually  in 
the  middle  line  of  the  dorsum  and  just  behind  the  corona  (Fig.  571). 

Use  the  point  of  the  knife,  making  short,  firm,  shallow  cuts,  until 
the  constricting  band  is  felt  to  yield.  A  too  bold  incision  may  result 
in  seriously  wounding  the  corpora  cavernosa. 


Fig.  651. — Dividing  the  constricting  band  in  paraphimosis.     (Veau.) 

The  bleeding  in  any  event  will  usually  be  free  but  ceases  spontane- 
ously. The  wound  which  at  first  was  vertical,  becomes  transverse 
when  reduction  is  completed,  and  is  sutured  in  that  direction. 

Apply  a  moist  dressing  and  if  there  is  no  ulceration  or  gangrene,  the 
swelling  will  soon  subside.  But  in  this  case  also  the  patient  must  be 
advised  of  the  danger  of  recurrence  unless  a  circumcision  is  done  for 
the  relief  of  the  narrowed  prepuce  or  the  short  frenum  after  the  in- 
flammation has  subsided. 

CIRCUMCISION 

This  is  an  excellent  operation  probably  not  often  enough  done  in 
infancy,  when  it  is  simple  and  without  danger,  and  may  prevent  the 
disturbances  of  adolescence,  consequent  upon  phimosis. 


CIRCUMCISION 


793 


In  adult  life  it  is  often  the  primary  step  toward  tlie  relief  of  acute 
disorders  and  sexual  irregularities. 

The  Operation. — General  anesthesia  is  nearly  always  indicated  in 
children;  local,  in  adults.  To  secure  local  anesthesia,  begin  by  lightly 
tamponing  the  preputial  orifice  with  a  pledget  of  cotton  saturated 
with  a  lo  per  cent,  solution  of  cocaine,  and  left  in  position  for  at  least 
five  minutes.  Next  inject  the  foreskin  in  the  line  of  the  proposed 
incision,  using  a  4  per  cent,  solution  of  cocaine  or  Schleich's  solu- 
tion. The  too  rapid  absorption  of  cocaine  may  be  prevented  by 
constriction  of  the  base  of  the  penis. 


Fig.  652. — Resection  of  the  prepuce.     {Veau.) 

When  the  anesthesia  is  established,  break  up  the  preputial  ad- 
hesions with  a  grooved  director  or  probe,  usually  not  difficult  in  an 
infant  but  sometimes  difficult  in  the  adult,  following  balanitis. 

There  are  various  methods  of  making  the  incision,  any  of  which, 
properly  employed,  will  give  good  results.  Suppose  the  prepuce  is 
long  and  slender:  begin  by  holding  the  penis  vertically  and  without 
making  traction  on  the  foreskin,  apply  a  forceps  so  that  its  blades  lie 
parallel  with  the  oblique  line  of  the  corona  (Fig.  652).  Use  care,  of 
course,  not  to  pinch  the  glans.  Divide  the  foreskin  wdth  the  bis- 
toury, allowing  the  blade  to  hug  the  upper  side  of  the  forceps,  that  no 
bruised  tissues  mav  be  left  behind.     The  skin  retracts,  leaving  the 


794 


CIRCUMCISION 


mucosa  covering  the  glans.  Divide  this  mucous  covering  along  the 
middle  line  to  within  J^  inch  of  the  coronal  border  (Fig.  653). 
The  glans  will  now  be  completely  exposed. 

Trim  off  the  two  mucous  flaps  so  that  a  narrow  cuff  is  left.  It  is 
better  to  begin  near  the  f  renum  and  trim  toward  the  terminal  point  of 
the  dorsal  incision  (Fig.  654).  If  the  f renum  is  too  short,  divide  it 
transversely  with  the  scissors  (Fig.  655),  catching  up  the  little  artery 
which  will  be  divided.     This  completes  the  necessary  incisions. 


Fig.  653, — Splitting  the  mucous  membrane.     (Veau.) 


Eemostasis  must  be  assured.  It  may  be  necessary  to  tie  two  or 
three  small  vessels  and  nearly  always  the  artery  of  the  frenum  re- 
quires ligation,  using  catgut  No.  i. 

A  brief  application  of  adrenalin  solution  on  a  compress  will  check 
the  oozing  if  it  should  persist. 

Suture.  The  mucous  and  cutaneous  borders  are  brought  into 
exact  contact  and  united  by  several  small,  interrupted  sutures  of 
catgut  (Fig.  656).  The  transverse  incision  of  the  frenum  is  made  a 
vertical  one  by  extending  the  glans,  and  is  sutured  in  that  direction 
(Fig.  657). 

In  the  case  of  children,  it  may  be  sufficient,  instead  of  suturing,  to 
use  small  clips,  by  which  means,  it  is  claimed,  swelling  is  avoided. 

Dressing. — Wrap  the  penis  in  a  sterile  compress,  leaving  the  glans 


CIRCUMCISION 


795 


Fig.  654. — Resection  of  the   mucous   mem-     Fig.  655. — Section  of  the  frenum,     (Veau.) 
brane.     {Veau.) 


Fig.  656. — Maintaining  coaptation  by  means     Fig.  657. — After  section  of  the  frenum  the 
of  a  small  clip.     (Veau.)  raw  edges  are  coapted.     (Veau.) 


796  HYDROCELE 

exposed.  Enclose  the  whole  in  a  second  compress  perforated  over 
the  meatus,  and  secure  with  adhesive  strips. 

Adults  require  bromides  to  prevent  painful  erections.  The  dress- 
ings are  not  to  be  changed  unless  soiled.  Remove  the  sutures  and 
re-dress  the  fifth  day.  It  wdll  probably  require  ten  to  twelve  days 
for  repair  to  be  complete. 

Children  usually  need  a  daily  change  of  dressing.  If  clips  are 
used  instead  of  sutures,  they  are  to  be  removed  at  the  end  of  twenty- 
four  hours,  and  if  the  adjustment  was  perfect,  the  reunion  by  that 
time  will  often  be  practically  complete. 

HYDROCELE 

The  chief  test  of  a  hydrocele  is  its  "translucency."  The  first 
treatment  usually  tried  is  tapping  and  the  injection  of  an  alterative. 
If  the  hydrocele  recurs,  then  a  radical  operation  should  be  done. 
Often  this  should  be  resorted  to  from  the  first  without  preliminary 
tapping,  especially  in  the  long-standing  cases,  where  the  tunica 
vaginalis  is  thickened  and  it  is  almost  obvious  that  the  trouble  wall 
recur. 

Occasionally  the  patient  will  prefer  repeated  simple  puncture  and 
evacuation  without  subsequent  injection,  rather  than  the  more 
radical  procedures  which  will  lay  him  up  for  some  days. 

Tapping. — -Anesthesia  is  not  necessary.  Prepare  the  field  as  for 
a  surgical  operation.  Seize  the  tumor  behind  with  the  left  hand  so  as 
to  make  it  tense  in  front.  The  trocar,  held  in  the  right  hand  with 
index  finger  an  inch  from  the  point  to  limit  its  penetration,  is  entered 
with  a  sharp  thrust  into  the  middle  and  lower  part  of  the  anterior 
surface  of  the  tumor  (previously  assure  yourself  that  the  testicle  is 
not  inverted).  Withdraw  the  plunger,  being  careful  that  the  tube  is 
not  displaced.  When  the  fluid  is  evacuated,  attach  a  syringe  to  the 
trocar  and  inject  a  drachm  of  a  J^^  per  cent,  solution  of  cocaine; 
gently  massage  the  scrotum  so  as  to  bring  the  solution  in  contact 
with  the  whole  testicle,  wait  ten  minutes  and  then  let  the  solution 
flow  out. 

In  the  meantime  charge  the  syringe  with  a  drachm  of  pure  tincture 


HYDROCELE 


797 


o\  iodine  and  inject.     Ilt)ld  it  for  live  minutes  and  then  let  it  escape. 
Withdraw  the  trocar  and  seal  the  puncture  with  collodion. 

The  next  day  the  scrotal  wall  is  painful,  reddened  and  swollen. 
The  scrotum  must  be  well  supported,  and  moist  compresses  may  give 
some  rehef.  The  patient  should  be  kept  in  bed  for  ten  days  and 
warned  that  several  weeks  may  be  required  for  absorption  of  the 
exudates. 


Fig.  658. — Incision  for  hydrocele.     (Veau.) 


RADICAL   OPERATION 


Sterilize  the  penis,  scrotum,  and  perineum.  Wrap  the  penis  in  a 
sterile  compress  and  have  it  held  out  of  the  way. 

Local  anesthesia  may  be  employed,  but  a  general  anesthesia  is 
better. 

Make  an  incision  2  inches  long  over  the  middle  of  the  tumor, 
dividing  first  the  several  layers  over  the  tunica  (Fig.  658).  Then 
open  the  tunica  the  whole  length  of  the  wound  and  evert  the  testicle. 
The  tunica  is  stitched  to  the  cord  above  and  its  free  borders,  brought 
together  behind  the  epididymis,  are  to  be  sutured  to  each  other 


798  CASTRATION 

(Fig.  659).  Or,  the  membrane  may  be  resected  completely,  follow- 
ing close  to  the  epididymis,  and  if  the  cut  edges  bleed,  they  are  to  be 
sewed  with  a  continuous  suture  (Fig.  660). 

Restore  the  testicle,  insert  a  small  drain,  and  suture  the  scrotum. 
The  drain  should  be  removed  on  the  second  day  and  the  sutures  on 
the  sixth,  and  in  a  day  or  two  longer,  the  patient  may  get  up. 


Fig.  659. — Everting  the  tunica  vaginalis.     (Veau.) 

CASTRATION 

The  removal  of  the  testicle  is  more  frequently  indicated  as  the 
result  of  cancer  or  tuberculosis,  and  may  be  done  under  either  local 
or  general  anesthesia. 

The  incision  begins  just  below  the  external  ring  (on  the  right) 
and  follows  the  direction  of  the  cord  for  from  i3-^  to  2  inches 
(Fig.  661). 

Expose  and  isolate  the  cord  up  to  the  inguinal  canal  which,  if  in- 
volved, should  be  opened,  as  in  the  operation  for  hernia.  Separate 
the  different  elements  of  the  cord,  so  as  to  require  two  or  three  sepa- 
rate ligatures.  Do  not  include  the  cremaster  in  the  ligatures 
(Fig.  662).  Just  below  the  catgut  ligatures,  resect  the  cord  and  enu- 
cleate the  testicle  from  above  downward  (Fig.  663). 


CASTRATION 


799 


KiG.  660. — Hydrocele.     Resection    of  the  Fig.  661. — Incision  for  castration.     (Veau.) 

tunica  vaginalis.     {Veau.) 


Fig.  662. — ^Ligation  of  the  spermatic  cord.     (Veau.) 


8oO  CASTRATION 

This  step  is  usually  tedious  in  the  tubercular  cases  on  account  of 
the  adhesions  which  may  have  to  be  divided  with  the  bistoury,  and 
the  bleeding  points  tied. 

Again  inspect  the  cord  (you  have  left  the  ligatures  long  till  now) 
to  be  sure  there  is  no  bleeding;  and  it  is  recommended  to  cauterize 
the  end  of  the  vas  in  tuberculosis. 


Fig.  663. — Separating  the  testicle  from  the  scrotal  tissues.      {Veau.) 

Repair  first  the  inguinal  canal,  if  it  was  opened.  Insert  a  drain- 
age-tube reaching  to  the  bottom  of  the  scrotum  and  projecting  from 
the  upper  angle  of  the  wound  which  is  the  point  least  likely  to  get 
infected  after  the  dressings  are  applied.  The  tubercular  cases  espe- 
cially require  drainage.  Suture  and  apply  a  dry  dressing.  Remove 
the  tube  on  the  third  and  the  sutures  on  the  sixth  or  seventh. 


CHAPTER  XXV 
INGROWING  TOE-NAIL 

The  particular  point  in  this  operation  is  to  obliterate  the  matrix 
corresponding  to  the  part  of  the  nail  removed.  It  is  insufficient  to  re- 
move only  that  part  of  the  nail  gouging  the  flesh.  Usually  one  side 
only  is  involved,  the  outer  side,  and  the  removal  of  half  the  nail  will 
effect  a  cure. 


Fig.  664. — Local  anesthesia.     {Veau.) 

Employ  local  anesthesia.  Constrict  the  base  and  make  a  circular 
injection  of  cocaine  or  stovaine  (Fig.  664). 

Remove  the  Nail.  Introduce  the  sharp  point  of  the  scissors  under 
the  nail  and  divide  its  entire  length  (Fig.  665).  Next  seize  the  dis- 
eased portion  with  a  forceps  and  tear  it  out  (Fig.  666). 

Extirpate  the  Matrix.  Incise  the  integument  of  the  matrix  to  be 
eliminated,  with  a  sharp-pointed  bistoury,  holding  the  cutting  point 
51  801 


802 


INGROWING   TOE-NAIL 


Fig.  665. — Splitting  the  nail.     (Veau.)  Fig.  666. — Wrenching  the  nail  out.    (Veau. 


Fig.  667. — Incision  over  the  matrix.    (^Veau.)       Fig.  C68.— Extirpation  of  matrix.   (Veau.) 


INGROWING   TOE-NAIL 


803 


obliquely,  so  that  it  gets  a  larger  bite  deeply  than  superficially  (Fig. 
667).  The  soft  parts  are  thus  removed  down  to  the  bone  (Fig.  668). 
A  deep  cavity  is  left  in  the  bottom,  of  which  the  bone  may  be  seen 
(Fig.  669).     This  cavity  should  be  packed  with  sterile  gauze  and 


A.M 


Fig.  669. — The  matrix  removed.     (FeaM.) 


Fig.  670. — Wound  sutured.     {Veau.') 


allowed  to  heal  by  granulation,  which  will  require  two  or  three  weeks. 
It  is  advisable  to  diminish  the  size  of  the  cavity  by  a  suture,  including 
on  one  side  the  skin,  and  on  the  other,  the  subungual  tissues  (Fig. 
670).     It  will  probably  give  way  finally,  yet  it  facilitates  repair. 


CHAPTER  XXVI 

REMOVAL  OF  SMALL  TUMORS 

The  technic  for  the  removal  of  small  tumors  on  or  under  the  skin 
should  be  kept  in  mind.  As  in  more  difficult  operations,  a  definite 
procedure  should  be  followed.  A  lack  of  system  may  make  a  minor 
matter  one  of  difficulty. 

Local  anesthesia  will  usually  suffice.  It  should  be  complete.  To 
secure  a  complete  local  anesthesia,  begin  by  determining  the  lines  of 
incision,  and  along  these  lines  inject  a  2  per  cent,  solution  of  co- 


FiG.  671. — Anesthesia  of  the  skin. 
{yeau.) 


Fig.  672. — Anesthesia  of  the  deeper  layers. 
{Veau.) 


caine;  intradermic,  not  subcutaneous.  If  the  tumor  is  large  or  if  the 
skin  is  loose,  redundancy  may  be  avoided  by  making  two  semicircu- 
lar incisions,  thus  removing  an  ellipse  of  the  skin  (Fig.  671). 

Next  loosen  the  edges  of  the  skin  and  partially  expose  the  tumor 
and  make  a  new  injection  along  its  sides.  Later  inject  the  base  of  the 
tumor  as  the  dissection  proceeds  (Fig.  672). 

In  the  case  of  sebaceous  cysts,  the  main  point  is  to  remove  the  sac  in 
its  entirety;  anything  else  insures  a  return  of  the  trouble.     If  possible, 

804 


REMOVAL   OF   SMALL   TUMOKS 


805 


dissect  the  sac  out  without  emptying  its  contents.  The  dissection 
will  be  done  with  ease  only  in  case  all  the  layers  are  incised  down  to 
the  true  capsule.  If  the  cyst  walls  are  particularly  thick,  the  contents 
may  be  emptied  out  from  the  first. 

Once  the  cyst  is  exposed  retract  one  lip  of  the  skin  wound  and 


Fig.  673. — Detaching  the  capsule.     {Veau.) 


Fig.  674. — Dissecting  a  loose  capsule  with  the  bistoury.     {Veau.) 

loosen  the  attachments  by  blunt  dissection  (Fig.  673).  Or  if  the 
fibrous  attachments  are  loose  and  tough,  divide  them  with  scissors  or 
scalpel  (Fig.  674). 

There  will  be  some  slight  hemorrhage  from  the  cavity  following 
the  removal  of  the  cyst,  but  it  will  be  easily  controlled  by  pressure  or 
by  a  hot  compress.     In  case  the  cyst  was  emptied  in  the  course  of  the 


8o6  REMO\'AL    OF    S^A.LL   TUMORS 

operation,  be  assured  that  all  the  cyst  wall  is  removed,  or  the  growth 
will  recur. 

The  procedure  is  the  same  in  the  case  of  a  fatty  tujyior  unless  it  is 
pedunculated;  if  so,  make  a  curved  incision  on  each  side  of  its  base. 
Usually  a  small  blood  vessel  at  the  base  of  the  tumor  will  require 
ligation. 

Synovial  cysts  require  special  attention  to  asepsis  or  the  cavity  with 
which  they  are  connected,  and  from  which  they  originate,  may  be- 
come infected;  thus  an  arthritis  or  teno-synovitis  might  develop. 
The  pedicle  requires  careful  ligation. 

Branchial  cysts  are  often  intimately  connected  with  the  vessels  in 
the  neck  and  their  dissection  may  be  extremely  difficult.  The  pedicle 
of  such  cysts  usually  terminates  in  the  thyro-glossal  duct. 

Angiomas  are  likely  to  give  rise  to  dangerous  hemorrhage.  Only 
such  as  are  small  and  well  defined  should  be  undertaken  by  the  prac- 
titioner. No  effect  should  be  made  to  enucleate;  instead  elliptical 
incisions  should  be  made  quite  beyond  the  borders  of  the  tumor  and 
the  whole  removed  ^^ en  masse."^  Usually  a  well-defined  vascular 
pedicle  will  require  careful  ligation. 


CHAPTER  XXVII 

SKIN    GRAFTING 

Skin  grafting  is  a  measure  deserving  to  be  more  generally  employed 
by  the  practitioner.  Very  often  it  would  save  time  and  trouble  in  the 
treatment  of  those  conditions  in  which  epidermitization  is  long  de- 
layed, for  this  it  hastens  and  also  it  tends  to  prevent  the  formation  of 
scar  tissue.  Thus  chronic  ulcers,  burns,  and  lacerated  wounds  fol- 
lowed by  extensive  sloughs  may  require  grafting. 

The  operation  is  simple  in  theory  yet  attended  by  many  failures 
through  lack  of  attention  to  detail. 

Three  factors  require  the  minutest  supervision:  (i)  the  field  must 
be  properly  prepared;  (2)  the  grafts  must  be  cut  correctly;  (3)  the 
after-treatment  must  be  appropriate. 

(i)  The  area  to  be  grafted  must  be  sterile  and  must  be  free  of  any 
oozing.  If  an  ulcer  is  to  be  treated,  the  granulations  must  previously 
be  made  as  healthy  as  possible:  if  sluggish,  by  currettement ;  if  exuber- 
ant, by  touching  up  with  nitrate  of  silver.  A  few  days  afterward  it 
will  be  ready  to  receive  the  graft.  A  dry  sterile  dressing  should  be 
applied  a  day  previous  to  the  operation;  before  the  graft  is  applied, 
the  surface  should  be  thoroughly  douched  with  normal  salt  solution. 

(2)  The  skin  which  is  to  furnish  the  graft  should  be  shaved  and 
thoroughly  scrubbed  with  soap  and  water.  Antiseptics  had  better 
be  avoided  for  they  may  compromise  the  vitality  of  the  cellular  ele- 
ments. A  sufficient  anesthesia  may  be  obtained  by  injection  of 
Schleich's  solution  No.  3. 

Two  methods  of  cutting  the  grafts  are  currently  employed,  Rever- 
din's  and  Thiersch's. 

(I)  Rtverdin's  Method. — A  small  fold  of  the  skin  is  picked  up  with 
fine  tissue  or  mouse-toothed  forceps  and  cut  off  at  its  base  with  small 
pointed  scissors  (Fig.  675).  This  section  includes  practically  all  the 
layers  of  the  skin  (Fig.  676).     The  graft  is  applied  and  gently  pressed 

807 


8o8 


SKIN    GRAFTING 


out.  Fifteen  or  twenty  points  are  thus  placed  about  15  mm.  or 
say  )4.  inch  apart.  If  the  surface  is  large  enough  to  require  more,  the 
center  should  be  left  bare  and  treated  by  a  second  operation  (Fig. 
677). 


Fig.  675. — Manner  of  cutting  the 
Reverdin  graft.     {Veau.) 


Fig.  676. — The  graft 
removed.      (Feow.) 


(II)  Thiersch's  Method. — 'This  method  is  the  better  when  it  suc- 
ceeds, but  the  conditions  of  success  are  more  exacting.     Granulation 

tissue  usually  needs  to  be  removed  by  currettement,  exposing  the 


Fig.  677. — Placing  Reverdin  grafts.     Ulcer  of  leg.     (Veau.) 

fibrous  layer.  The  edges  of  the  ulcer  must  be  scraped  (Fig.  678). 
The  oozing  which  follows  must  be  completely  checked.  A  firm  com- 
press applied  for  ten  or  fifteen  minutes  will  usually  suffice.  If  oozing 
persists,  the  operation  will  fail. 


SKIN   GRAFTING 


809 


The  grafts  in  this  case  consist  of  thin  slices  of  the  epidermis,  as  long 
as  necessary  and  as  wide  as  convenient.     They  are  usually  taken 


Fig.  678. — Thiersch's  method.     Preparing  the  wound  for  the  graft.     {Veau.) 

from  the  anterior  surface  of  the  thigh.     A  sharp,  thin-bladed  razor 
is  used  in  cutting  the  slice  (Fig.  679). 


Fig.  679. — Cutting  the  Thiersch  graft.     (Veau.) 


The  skin  must  be  put  on  the  stretch.     Special  retractors  are  occa- 
sionally employed.     The  two  hands  of  the  assistant  and  the  left  hand 


8io 


SKIN   GRAFTING 


of  the  operator  can  make  it  sufficiently  tense  (Fig.  680).  The  razor 
is  held  nearly  horizontally  and  cuts  by  a  rapid,  short,  sawing  motion. 
As  the  razor  progresses,  the  thin  and  pliable  tissue  piles  up  on  the 
blade. 

The  graft  is  now  applied  to  the  raw  surface  and  the  free  end  fixed 
by  a  pointed  instrument  and  slowly  worked  of  the  blade,  and  then 
teased  out  flat  (Fig.  681). 


Fig.  680. — Cutting   the   Thiersch   graft.     (Veau.) 


So  proceed  until  the  whole  surface  is  covered.  Small  angles  may 
be  filled  in  with  Reverdin  grafts  (Fig.  682).  The  area  denuded  need 
only  to  be  covered  with  a  sterile  dressing  and  repair  will  soon  be 
complete. 

(3)  The  grafted  area  must  be  carefully  covered  with  strips  of 
rubber  tissue  or  gutta-percha,  placed  in  various  directions  so  as  to 
hold  the  grafts  in  place  and  at  the  same  time  give  exit  to  any  exudates. 
A  layer  of  gauze  saturated  with  salt  solution  is  next  applied,  which  in 


SKIN   GRAFTING 


8ll 


turn  is  covered  by  absorbent  cotton,  and  the  whole  held  in  place  by  a 
moderately  firm  ba'ndage. 


Fig.  68  r. — Method  of  applying  the 
graft.     (Veau.) 


Fig.  682. — Wound  covered  by 
grafts.     (Veau.) 


The  part  should  be  immobilized,  employing  plaster  splints  if 
necessary.  Change  all  the  dressings  except  the  rubber  tissue  every 
day  or  two  and  douche  gently  with  normal  salt  solution.  At  the 
end  of  a  week  or  ten  days,  change  the  tissue. 


INDEX 


Abdomen,  contusions,  125 

gunshot  wounds,  151,  171,  219 

incised  wounds,  130 

injuries,  125 

laparotomy,  131 

non-penetrating  wounds,  127 

penetrating  wounds,  129 

punctured  wounds,  129 

stab  wounds,  129 
Abdominal  drainage,  131 

hemorrhage,  533 

section,  531 
Abducens  ner\^e,  396 
Abscess,  acute,  375 

alveolar,  384 

anal,  403 

antrum,  mastoid,  527 

appendicial,  571 

axillar>^  395 

Bartholin's  gland,  410 

breast,  393 

cervical  glands,  392 

chronic,  378 

definitions,  375 

dental,  384 

drainage,  377 

external  auditory  meatus,  382 

eyelids,  381 

face,  380 

floor  of  the  mouth,  386 

iliac,  418 

ischio-rectal,  400 

kidney,  552 

labium,  410 

lachrymal,  382  ^ 

liver,  414 


Abscess,  lung,  502 

mammary,  393 

mastoid,  522 

nasal  septum,  381 

palmar,  398 

parotid,  382 

pelvic,  411 

peri-anal,  403 

perineal,  404 

plantar,  400 

popliteal,  398 

prostatic,  404 

psoas,  418 

rectal,  403 

retropharyngeal,  389 

scalp,  subaponeurotic,  379 
subperiosteal,  380 
superficial,  379 

seminal  ducts,  408 

submammary,  385 

submaxillary,  385 

subphrenic,  414 

symptoms  of,  375 

tongue,  388 

tonsillar,  388 

treatment,  acute,  376 
chronic,  378 

urinary,  712 

vulvar,  409 

vulvo-vaginal,  410 
Accidents,  anesthesia,  16 
Actual  cautery,  phlegmon,  430 
Acupressure,  61 
Acute  intestinal  obstruction,  577 

retention  of  urine,  698 
Adrenalin  chloride,  anesthesia,  16 


813 


8i4 


INDEX 


Adrenalin  chloride,  epistaxis,  68 

gauze  tape,  64 

shock,  55 
Air  passages,  foreign  bodies,  459 

burns,  472 
Alcohol,  antisepsis,  3 
Allison,  strangulated  hernia,  609 
Alveolar  abscess,  384 
Ammonia  after  anesthesia,  18 
Amputations,  arm,  749 

Chopart,  765 

elbow,  748 

finger,  730 

foot,  767 

forearm,  745 

general  technic,  728 

great  toe,  761 

hand,  745 

hip-joint,  778 

index  finger,  atypical,  736 

knee-joint,  775 

leg,  772 

little  finger,  735 
toe,  762 

metacarpal,  739 

metatarsal,  764 

middle  finger,  733 
toes,  762 

Pirogoff's,  769 

principles,  728 

Syme's,  770 

thigh,  777 

thumb,  atypical,  744 
typical,  738 

toes,  760 

scapulo -humeral,  759 

shoulder,  749 
Anal  abscess,  403 

dilatation,  783 

fistula,  789 
Anastomosis,  intestinal,  650 
Andrews,  CoUes'  fracture,  245 
Anesthesia,  12 

accidents,  16 

ammonia,  18 


Anesthesia,  chloroform,  12 

cocaine,  18 

ether,  14 

ethyl  chloride,  18 

local,  18 

spinal,  22 

stovaine,  19 

vomiting,  17 
Anesthetics,  3 
Aneurism,  gunshot,  138 
Aneurismal  varix,  138 
Angina,  Ludwig's,  386 
Angiomas,  806 
Angus,  torsion,  671 
Ankle  amputation,  769 

arthrotomy,  446 

dislocation,  336 

fracture,  276 

sprain,  343 
Anterior  crural  ner\^e,  exposure,  367 

injury'',  366 
Anterior  tibial  artery,  ligation,  725 

nerve,  injury,  371 
Antipyrine,  epistaxis,  68 
Antisepsis,  emergency,  6 
Antiseptics,  3 
Antitetanic  serum,  199 
Antistreptococcic  serum,  phlegmon, 

431 

Antrum,  mastoid,  522 
Anus,  abscess,  403 

artificial,  permanent,  593 
temporar}^  589 

dilatation,  783 

fistula,  789 

imperforate,  662 

piles,  784 
Appendectomy,  563 
Appendicial  abscess,  571 
Appendicitis,  557 

after-treatment,  574 

catarrhal,  559 

diagnosis,  557 

gangrenous,  561 

operation,  567 


INDEX 


8iS 


Appendicitis,  perforating,  561 
treatment,  563 
ulceration,  561 
varieties,  560 
Appendix  in  hernia,  615 
Arm,  amputation,  749 
bandages,  45 
fractures,  209 
phlegmons,  429 
Army  bullet,  135 
Aristol  in  burns,  471 
Arrest  of  hemorrhage,  60 
Arterial  hemorrhage,  57 
Arteries,  ligations,  rules,  717 
suture,  717 
torsion,  62 

wounds,  gunshot,  138 
Artery  forceps,  4 

ligation,  anterior  tibial,  725 
axillary,  722 
brachial,  722 
common  carotid,  719 
compression,  66 
dorsalis  pedis,  726 
external  carotid,  720 
femoral,  724 
lingual,  720 
obturator,  368 
posterior  tibial,  726 
radial,  723 
subclavian,  720 
ulnar,  724 
Artificial  anus,  permanent,  593 
temporary,  589 
limbs,  772 
respiration,  17 
Arthritis,  septic,  440 
Arthrotomy,  441 
ankle,  446 
elbow,  447 
hip,  448 
knee,  441 
shoulder,  448 
wrist,  448 
Arx,  heart  injuries,  125 


Asphyxia,  anesthesia,  16 

foreign  bodies,  456 

retropharyngeal  abscess,  389 
Aspiration,  bladder,  707 

pericardium,  498 

pleura,  504 
Astragalus,  dislocation,  336 

fracture,  280 
Auditory  nerve,  injuries,  359 
Automatic  centers,  paralysis,  13 
Axillary  artery,  ligation,  722 

abscess,  acute,  395 
chronic,  395 
Axtell,  wound  of  chest,  119 

trephining,  520 

Bandage,  arm,  45 
Barton's,  47 
breast,  44 
eye,  47 
finger,  44 
foot,  38 
groin,  41 
hand,  45 
head,  47 
knee,  41 

leg,  41 

neck,  45 

shoulder,  45 

St.  Andrew's  cross,  44 

stump,  48 

thumb,  45 
Bandages,  37 

method  of  applying,  38 

plaster,  49 
Bartholin's  gland,  abscess,  410 
Barton's  bandage,  47 
Base  of  thorax,  wounds,  120 
Bassini,       operation      for      hernia, 

632 
Bavarian  splints,  51 
Belfield,  drainage  of  seminal  ducts, 

408 
Bellocq's  cannula,  69 
Bennett,  Sir  W.,  torsions,  670 


8i6 


IXDEX 


I 


Bennett's  fracture,  247 

Biceps  tendon  dislocation,  347 

Bi-coude  catheter,  699^ 

Bier  treatment,  424 

"Black  eye,"  382 

Bladder,     aspiration    in    retention, 

707 
Bladder,  cystotomy,  708 

foreign  bodies,  467 

hernia  operation,  614 

gunshot  wounds,  153 

puncture,  707 

rupture,  553 

suture,  555 

wounds,  554 
Blank  cartridges,  198 
Bleeding  fsee  Hemorrhage) 
Bloodgood,    intestinal    obstruction, 

577 

fractures,  203 
Blood  vessels,  injuries,  92,  95 
Bolo  wounds,  173 
Bone  plating,  275 

wiring,  234 
Bonney,  emergency  operations,  6 
Bowel,  acute  obstruction,  577 
Bowls,  sterilization,  9 
Brachial  arter\%  compression,  66 

ligation,  722 
Brain,  abscess,  166 

compression,  306 

concussion,  304 

contusion,  306 

gunshot  wounds,  146,  166 

hemorrhage,  510 

injuries,  299 

topography,  510 
Branchial  cysts,  806 
Breast  abscesses,  393 

bandage,  44 
Brickner,  tubal  pregnancy,  676 
Bronchi,  foreign  bodies,  459 
Bronchoscopy,  Killian,  461 
Brown,  Cesarean  section,  684 
Bruises  (see  Contused  wounds) 


Brushes,  hand,  2 

Bryant,  esophagotomy,  486 

vertical  extension,  262 
Btillet  wounds,  civU,  186 

military,  133 
Bullets,  types,  135 
Burmeister,      preparation     of     the 

hands,  10 
Burns  and  scalds,  468 
Burns,  air  passages,  472 
Burns,  electrical,  473 
Burns,  mouth,  472 

Cahill,  torsions,  670 

Calmette's       antitetanic       powder, 

199 
Cannaday,       subcuticular       suture, 

31 
Capitellum,  46 
Carbuncle,  38 1 
Carotid  artery  compression,  66 

ligation,  719 
Carpus,  dislocation,  342 

fracture,  246 
Carron  oil,  472 
Castration,  798 

emergency,  107 
Catgut,  26 

chromicized,  26 
Catheterization,  equipment,  699 

retrograde,  695 
Catheters,  acute  retention,  699 

box  for,  4 

sterilization,  699 
Cecum  in  hernia,  613 
Cerebro-spinal      fluid,      characters, 

300 
Cervical  glands,  suppuration,  392 
Cesarean  section,  682 
Championniere,  fractures,  205 
Charlton,  foreign  body  in  bladder, 

467 
Chest  contusions,  114 

wounds,  no 
Cheyne,  phlegmon  of  neck,  431 


INDEX 


817 


Chipniaii,     reduction    of    shoulder, 

321 
Chloral,  wounds  of  tongue,  85 
Chloroform  anesthesia,  12 

face  in,  13 

pulse  in,  13 

pupil  in,  13 
container,  13 
Chopart's  amputation,  765 
Cigarette  drain,  33 
Circular  enterorrhaphy,  654 
Circumcision,  792 
Circumflex  nerve,  exposure,  366 

injury,  366 
Clavicle,  fracture,  290 
Cocaine,  4 

anesthesia,  18 
Coley,  femoral  hernia,  569 
Collapse,  53 
Colles'  fracture,  242 
Colon  bacillus,  557 
Colostomy,  593 
Colpotomy,  348,  411 
Combs,    foreign    body    in    rectum, 

464 
Comminuted  fractures,  168,  200 
Compound  dislocations,  338 

elbow,  340 

hip,  340 

knee,  342 

shoulder,  340 

wrist,  342 
fractures,  283 

ankle  and  foot,  288 

tibia,  286 
Compression  of  arteries,  brachial,  66 

carotids,  66 

coronary,  66 

facial,  66 

femoral,  67 

intercostals,  68 

occipital,  66 

plantar,  68 

popliteal,  67 

subclavian,  66 

52 


Compression  of  arteries,  temporal,  66 
tibial,  67 
ulnar,  66 

of  brain,  304 
Concussion  of  brain,  304 
Condyles  of  humerus,  fracture,  230 
Congenital  hernia,  632 
Coin  catchers,  457 
Conjunctiva,  foreign  bodies,  451 

wounds,  91 
Continuous  suture,  27 
Contusions,  72 

abdomen,  125 

brain,  306 

chest  wall,  1 14 

eye,  89 

eyelid,  86 

knee-joint,  342 

lung,  114 

nerves,  358 

scalp,  81 

urethra,  689 
Cook,  appendicitis,  564 
Cooper,  reduction  of  elbow,  328 
Coracoid  process,  examination,  215 
Corner,  torsions,  674 
Coronary  artery,  compression,  66 
Cotton,  injuries  to  testicle,  108 
Cradle  splint,  164 
Cranial  nerves,  injuries,  359 
Craniectomy,  emergency,  510 
Crepitus,  201 
Crile,  direct  transfusion,  55 

shock,  55 
Crucial  ligaments,  rupture,  345 
Crushing  injuries  to  the  extremities, 

9: 

CuUen,  torsions,  674 
Cushing,  shock,  56 
Cut  throat,  86 

wrist,  91 
Cystotomy  operation,  695,  708 

Dayat,  foreign  bodies,  466 
Deep  epigastric  artery,  68 


8i8 


INDEX 


Dental  abscess,  384 
Depressed  fracture,  skull,  302 
Diaphragm,  wounds,  122 
Digital  arteries,  compression,  67 
Dilatation  of  the  anus,  783 
urethral  stricture,  701 
Direct     pressure     in     hemorrhage, 

60 
Dislocations,  312 
ankle,  336 
compound,  338 
elbow,  327 
finger,  33a 
hip,  330 
jaw,  326 
knee,  334 
patella,  336 
shoulder,  312 

after-treatment,  325 
subclavicular,  316 
subcoracoid,  312 
subglenoid,  322 
subspinous,  324 
semilunar  cartilages,  335 
thumb,  329 
wrist,  340 
Dixon,  tubal  pregnancy,  676 
Dorsalis      pedis      artery      ligation, 

726 
Dorsum  ilii,  dislocation,  330 
Double  spica,  37 
Downey,  fracture  of  femur,  260 
Doyen's  trephine,  514 
Drainage,  32 

abdominal,  131 
abscess,  377 
accidental  wounds,  32 
amputations,  728 
appendicitis,  571 
arthrotomy,  442 
aseptic  wounds,  32 
cigarette,  33 
compound  fractures,  34 
empyema,  508 
gauze  wick,  33 


Drainage,  heart  wounds,  495 

operative  wounds,  34 

tubes,  33 

urinary  infiltration,  716 
Dressings,  35 

first  aid,  153 

frequency,  36 
Dupuytren's  splint,  279 
Dura  mater,  wounds,  517 
Dutch  cane  splints,  48 
Dyspnea,  heart  wounds,  123 

Ear  drum,  paracentesis,  523 

forceps,  453 

foreign  bodies,  452 
Eastman,  J.  R.,  hernia,  640 

intestinal  obstruction,  578 
Eastman,  T.  B.,  appendicitis,  558 
Ectopic  gestation,  675 
Edema  of  glottis,  483 
Elbow,  amputation,  748 

arthrotomy,  447 

dislocation,  327 

fracture,  230 

gunshot  wounds,  159 

wound,  95 
Electrical  burns,  473 

shock,  473 
Elliott,  wounds  of  kidney,  553 
Emergency  antisepsis,  6 

operations,  preparation,  7 

surgery,  equipment,  2 
military,  185 
Emphysema,  chest  injuries,  113 
Empyema  of  thorax,  502 

adult,  506 

after-treatment,  509 

child,  505 

diagnosis,  502 

puncture  for,  504 
Enemas,  technic,  580 
Enterectomy,  650 
Enterorrhaphy,  653 
Enterostomy,  589 
Epistaxis,  68 


INDEX 


819 


Equipment,  emergencies,  2 
Esophagotomy,  484 
Esophagus,  foreign  bodies,  455 

wounds,  89 
Estes,  intussusception,  583 
Ether  anesthesia,  14 

adrenalin  chloride  in,  15 
External   auditory  meatus    abscess, 
382 

carotid  artery  ligation,  720 

urethrotomy,  691 
Extravasation  of  urine,  712 
Extremities,  crushing  injuries,  97 

fractures,  200 

wounds,  92 
Eye  bandage,  47 

foreign  bodies,  451 

injuries,  89 
Eyelid,  abscess,  381 

contusion,  86 

wounds,  86 

Face,  abscesses,  380 
fractures,  299 
furuncle,  380 
gunshot  wounds,  169,  190 
wounds,  84 
Facial  artery,  compression,  66 
ligation,  720 
nerve  injuries,  359 

mastoid  operation,  528 
Felon,  423 

Femoral  artery,  compression,  67 
ligation,  724 
stab  wound,  95 
hernia,  anatomy,  617 
radical  cure,  643 
strangulated,  617 
operation,  619 
taxis,  603 
Femur,  amputations,  777 
fractures,  252 

after-treatment,  260 
children,  262 
epiphyseal,  262 


Femur  fractures,  shaft,  257 
supracondylar,  260 
osteomyelitis,  438 
Fibula,  fractures,  276 
Field      of  operation,      sterilization, 

10 
Figure-of-eight  bandage,  38 
Fingers,  amputations,  731 

bandages,  44 

dislocations,  330 

fractures,  247 

infections,  422 
First  aid,  dressing,  153 

fractures,  208,  251 

hemorrhage,  65 

splints,  180 
Fiske,  wounds  of  spleen,  551 
Fistula,  anal,  789 

urinary,  712 
Fitzmaurice-Kelley,  amputation  for 

shell  wounds,  156 
Floor  of  mouth,  abscess,  386 
Florschutz  suspension,  165 
Foot,  amputations,  767 

bandages,  38 

fractures,  280 
Forceps,  artery,  5 

aural,  453 

nasal,  455 

urethral,  465 
Forcipressure,  61 
Ford,  ether  anesthesia,  16 

fracture  of  patella,  265 
skull,  419 
Forearm,  amputation,  745 

phlegmon,  427 
Foreign  bodies,  air  passages,  459 

bladder,  467 

ear,  452 

esophagus,  455 

eye,  451 

larynx,  459 

nose,  454 

pharynx,  455 

rectum,  462 


820 


INDEX 


Foreign  bodies,  trachea,  459 

urethra,  465 
Fountain  syringe,  3 
Fowling  piece,  gunshot  wound,  198 
Foxworthy,  bolo  wounds,  173 
Fractures,  200 

ankle,  276 

anterior  tuberosity  of  tibia,  276 

arm,  209 

astragalus,  280 

carpus,  246 

clavicle,  290 

Colics',  242 

compound,  283 

condylar,  230 

crepitus,  202 

definitions,  200 

diagnosis,  201 

elbow,  230 

extremities,  200 

face,  299 

gunshot,  1 69,  190 

femur,  252 

gunshot,  169,  190 

fibula,  276 

fingers,  247 

first  aid,  208 

foot,  280 

forearm,  237 

gunshot,  155,  159 

hand,  246 

head,  301 

humerus,  209 

immobilization,  205 

intercondylar,  232 

jaw,  lower,  309 
upper,  308 

leg,  270 

lower  extremities,  251 

malar,  308 

maxniae,  180,  308 

metacarpus,  246 

nasal  bone,  309 

olecranon  process,  233 

OS  calcis,  281 


Fractures,  pain,  202 

patella,  264 

pelvis,  297 

Pott's,  276 

prognosis,  201 

radius,  237 
head,  236 
lower  end,  241 

reduction,  204 

ribs,  295 

scapula,  294 

skull,  299 

compound,  303 

spine,  296 

splints,  207 

supracondylar,  225 

tarsus,  280 

thumb,  247 

tibia,  269 

toes,  282 

treatment,  204 

ulna,  237 

vertebra,  296 

wrist,  246 
Freezing,  474 
Frost  bite,  475 
Furuncle  of  face,  380 
Fysche,  gunshot  wound,  193 

Gage,  rupture  quadriceps  extensor, 

350 
Gangrene,  amputation,  728 
Garrison,  emergency  operations,  6 
Gastric  lavage,  14,  16,  580 
Gastro-enterostomy,  478 
Gauze,  4 

drainage,  33 

dressings,  35 
General   practitioner  as  emergency 

surgeon,  i 
Genito-crural  nerve  injury,  369 
Gerster,    treatment    of    peritonitis, 

576 
Gibbon,  suture  of  heart,  495 
Gloves,  rubber,  10 


INDKX 


821 


(looch's  s])lin(,  4S 

(lossct,  wounils  of  iu>rvc'S,  i,v> 

(^irangcr,  burns,  472 

(ircat  toe,  amputation,  761 

Groin,  bandage,  41 

Groves,  gunshot  fractures,  157 

Guibal,  subphrenic  abscess,  414 

Gunshot  fractures,  155,  159 

wound  of  abdomen,  151,  171,  192 

bladder,  153 

blood  vessels,  iT,H 

bone,  144 

brain,  146,  166 

cranium,  145,  166 

face,  169,  190 

fascia,  138 

hand, 197 

head,  187 

heart,  151 

intestine,  152 

joints,  145,  166,  195 

kidney,  153 

knee,  166,  195 

liver,  153 

lungs,  150 

muscles,  138 

neck,  169 

nerves,  139 

pancreas,  153 

rectum,  153 

skin,  137 

skull,  144,  167 

spine,  148,  170,  189 

spleen,  153 

stomach,  152 

thorax,  149,  171,  196 

trachea,  170 
wounds,  civil,  186 

effects  on  tissues,  137 

hemorrhage,  137 

military,  137 

prognosis,  153 

shock, 137 

suicidal,  188 

treatment,  153 


Gun-splint,  184 

Guyon,  catheterization,  705 

Hand,  abscess,  424 

amputations,  745 

bandages,  45 
brushes,  2 
fractures,  246 

gunshot  wound,  197 

infections,  424 

injuries,  100 

sterilization,  9 
Harrington's  solution,  10 
Harsha,  torsions,  670 
Hartmann,  splenectomy,  673 
Havard,  gunshot  wounds,  152,  172 
Haynes,  wounds  of  liver,  548 
Head  wounds,  81 

bandages,  47 
Heart,  gunshot  wounds,  151 

massage,  17 

repair,  490 

suture,  495 

wounds,  122 
Heile,  treatment  of  ileus,  587 
Hemarthrosis,  166,  197 
Hematoma,  72 
Hematuria,  552 
Hemopericardium,  114 
Hemopneumothorax,  112 
Hemoptysis,  1 1 1 
Hemorrhage,  57 

acupressure,  61 

adrenalin  chloride,  58 

arrest,  60 

arterial,  57 

capillary,  57 

chemicals  in,  60 

constitutional  effects,  57 

definitions,  57 

diagnosis,  58 

ectopic  gestation,  rupture,  675 

fatal,  58 

iirst  aid,  65 

forcipressure,  62 


822 


INDEX 


Hemorrhage,  heat,  60 

hypodermoclysis,  59 

infusion,  intravenous,  59 

intermediary,  57 

internal,  57 

kidney,  541 

laparotomy,  532 

liver,  541 

meningeal,  301 

mesentery,  541 

normal  salt  solution,  59 

operative,  60 

parenchymatous,  57 

primary,  57 

secondary,  57 

spleen,  541 

spontaneous  arrest,  60 

symptoms,  57 

torsion,  62 

tourniquets,  61 

treatment,  58 

tubal  pregnancy,  675 

venous,  57 
Hemorrhoids,  operations,  784 
Hemostasis,  60 
Hemothorax,  11 1 
Hennequin's  dressing,  211 
Hernia,  appendix,  615 

bladder,  614 

cecum,  613 

encysted,  613 

femoral,  643 

gangrenous,  609 

inguinal,  632 

interstitial,  614 

lumbar,  631 

lung,  113 

obturator,  628 

ovaries,  631 

perineal,  631 

properitoneal,  614 

radical  cure,  femoral,  643 
inguinal,  632 
umbilical,  626 
vaginal,  631 


Hernia,  sciatic,  631 

septic  absorption,  598 

sigmoid,  613 

stomach,  617 

strangulated,  598 

umbilical,  622 
Hernial  sac,  anomalies,  613 
Hernio-laparotomy,  613 
Hertzfeld,  epistaxis,  69 
He3rvTosky,  bullet  wound  of  blood 

vessels,  138 
Hilton,  abscess,  396 
Hip-joint,  arthrotomy,  448 

amputations,  778 

dislocations,  330 

gunshot  wounds,  166 
Hodgen's  splint,  262 
Holliday,  splenectomy,  550 
Humerus,  fractures,  209 

anatomical  neck,  220 

external  condyle,  229 

greater  tuberosity,  221 

gunshot,  157 

internal  condyle,  230 

lower  end,  222 

osteomyelitis,  437 

shaft,  209 

supracondylar,  225 

surgical  neck,  216 

upper  end,  213 
in  children,  221 
Hunt,  tubal  pregnancy,  681 
Hyde,  foreign  body  in  urethra,  467 
Hydrocele,  796 

radical  operation,  797 

tapping,  796 
Hypodermoclysis,  59 
Hysterectomy,  681 

Ice,  appendicitis,  563 
Ileus,  post-operative,  536 
Iliac  abscess,  418 
Ilio-inguinal  nerve  injury,  369 
Imperforate  anus,  662 
Incised  wounds,  73 


INDEX 


823 


Incised  wounds  of  elbow,  95 
of  neck,  88 
of  wrist,  92 
Index  finger,  amputation,  735 
Infected  wounds,  79 
Infections,  acute,  421 
Inferior  maxilla  fracture,  309 
Infiltration  of  urine,  712 
Ingrowing  toe-nail,  801 
Inguinal  hernia,  anatomy,  632 
radical  cure,  632 
strangulated,  598,  603 
Injuries,  abdomen,  125 
hand,  107 
joints,  312 
nerves,  357 
thorax,  no 
Instruments,  emergency,  5 
cleansing,  5 
preparation,  7 
Intercondylar  fractures,  232 
Intercostal  artery,  hemorrhage,  68 
Internal  mammary  artery,  68 
Interrupted  sutures,  29 
Interstitial  hernia,  614 

tubal  pregnancy,  679 
Intestinal  anastomosis,  650 
end  to  end,  654 
lateral,  657 
Murphy  button,  656 
termino-lateral,  660 
obstruction,  acute,  577 
gastric  lavage,  580 
laparotomy,  581 
rectal  enema,  580 
symptoms,  578 
treatment,  579 
resection,  651 
rupture,  127 
Intestines,  suture,  543 

wounds,  541 
Intracranial  hemorrhage,  510 
Intravenous    infusion,    hemorrhage, 

59 

shock,  55 


Intravenous  infusion,  technic,  59 
Intussusception,  582 

operation  for,  585 
Iodine,  sterilization  of  the  skin,  10 
Irrigator,  3 

Ischiatic  dislocation,  331 
Ischio-rectal  abscess,  400 

Jaw,  dislocation,  326 

fracture,  308 
gunshot,  169 
Joints,  contusions,  342 

dislocations,  312 
compound,  338 

gunshot  wounds,  145,  166 

hemorrhage  into,  146,  167 

incised  wounds,  343 

injuries,  312 

punctured  wounds,  342 

sprains,  282,  343 

stab  wounds,  342 

suppurations,  440 
Jonnesco,  spinal  anesthesia,  23 

Keen,  Cesarean  section,  684 
Kelley,  torsions,  667 
Kidney,  abscess,  552 

hemorrhage,  541 

injuries,  552 

removal,  552 

rupture,  552 

wounds,  552 
Killian,  bronchoscopy,  461 
King,  fracture  of  extremities,  201 
Knott,  suture  of  liver,  548 
Kocher,  shoulder  dislocation,  313 
Kollman,  filiform  guide,  703 
Konig,  preparation  of  the  skin,  10 
Knee,  amputation,  775 

arthrotomy,  444 

bandage,  41 

contusions,  342 

crucial  ligaments.  345 

dislocations,  334 

gunshot  wounds,  146,  167 


824 


INDEX 


Knee,  puncture,  445 

sprains,  343 

stab  wounds,  342 

wounds,  342 
Kiitner,  wounds  of  lung,  192 
Kyle,  foreign  body  in  nose,  455 

Labium,  abscess,  409 
Lacerated  wounds,  77 
Laceration  of  brain,  299 
Lachrymal  abscess,  382 
Lanphear,  Cesarean  section,  683 
Laparotomy    for    Cesarean    section, 
682 

general  technic,  530 

gunshot  wounds,  civil,  186 
military,  133 

intestinal  obstruction,  579 

for  traumatism,  537 
Laplace,  peritonitis,  576 
Laryngotomy,  484 
Larynx,  foreign  bodies,  459 

wounds,  88 
Lateral  anastomosis,  intestine,  657 

sinus  thrombosis,  523 
Lavage,  gastric,  151,  580 
Leg,  amputations,  772 

bandage,  41 

fractures,  269 

osteomyelitis,  435 
Lejars,  appendicitis,  563 

preparations  for  operation,  7 

reduction  of  shoulder,  313 
thumb,  329 

rupture  of  the  lung,  1 15 

splint  for  leg,  272 
Lembert  suture,  544 
Lichtenstern,  torsion,  673 
Ligation,  62 
Ligation  en  masse,  63 
Ligations,  anterior  tibial,  725 

arterial,  principles,  717 

axillary,  722 

brachial,  722 

common  carotid,  719 


Ligations,  dorsalis  pedis,  726 

external  carotid,  720 

facial,  720 

femoral,  724 

lingual,  720 

occipital,  720 

posterior  tibial,  726 

radial,  723 

subclavian,  720 

superior  thyroid,  720 

ulnar,  724 
Lingual  artery,  ligation,  720 
Link,  tracheotomy,  482 
Lipomas,  removal,  801 
Lips,  wounds,  85 
Little-finger  amputation,  735 
Little  toe  amputations,  762 
Liver,  hemorrhage,  541 

injuries,  546 

suture,  547 
Local  anesthesia,  18 
Lower  extremity,  fractures,  251 
Lower  jaw,  dislocation,  326 
Lowery,  compound  fracture,  285 
Luckett,  Fourth-of-July  injuries,  199 
Ludlow,  wounds,  diaphragm,  121 
Ludwig's  angina,  386 
Lung,  abscess,  502 

gunshot  wounds,  150 

hernia,  113,  118 

rupture,  116 

stab  wounds,  116 

suture,  490 

Malaleuca  sempervirens,  701 
Malar  bone  fracture,  308 
Mammary  gland  abscess,  393 
Marsee,  fracture  of  fingers,  24 

injuries  to  hand,  102 

suture  of  tendons,  355 
Martin,  Cesarean  section,  684 
Mastoiditis,  522 
Mastoid  operation,  523 
Materials  for  sutures,  25 
Maxilla,  fractures,  308 


INDEX 


825 


Mayo,  umbilical  hernia,  630 
Mayor's  sling,  293 
Meatus,  foreign  bodies,  452 
Median  nerve  exposure,  362 

injury,  361 
Meningeal  hemorrhage,  307 
Mesentery,  hemorrhage,  540 

repair,  541 
Metacarpals,  amputations,  743 

fracture  246 
Metal  splints,  50 

McEwen,  strangulated  hernia,  617 
McFarland,  antitetanic  powder,  199 
McGrath,  appendicitis,  564 
Middle-finger  amputation,  733 
IMiddle    meningeal    artery,    hemor- 
rhage, 307 
Miller,  kidney,  injury,  553 
Miller,  pelvic  abscess,  414 
Mitchell,  peritonitis,  574 
Morley,  bandage  for  eye,  47 
Morris,  appendicitis,  558 
Morrison,  wounds  of  eye,  89 
Mosetig-Moorhof  bone  wax,  434 
Mothe,  dislocation  of  shoulder,  317 
Motor-oculi  nerve  injury,  360 
Mouth  burns,  472 

Moynihan,    intestinal    anastomosis, 
650 

purulent  peritonitis,  573 
Murphy,  anesthesia,  24 
Murphy  button,  656 

purulent  peritonitis,  574 

suture  of  arteries,  717 
olecranon,  235 
Musculo-cutaneous  nerve,  371 
Musculo-spiral  nen'e  exposure,  371 

injury,  370 

Nares,  plugging,  68 
Nasal  bone,  fracture,  309 
septum,  abscess,  381 
Nassau,  esophagotomy,  487 
Nausea,  anesthesia,  17 
Neck,  bandage,  45 


Neck  wounds,  86 

gunshot,  169 
Neff,  rupture  of  urethra,  688 
Nelaton's  line,  251 
Nephrectomy,  553 
Ner\'e,  compression,  358 

contusion,  358 

grafting,  359 

suturing,  357 

wounds,  358 
gunshot,  139 
Nerves,  individual,  359 

abducens,  359 

anterior  crural,  367 

auditory,  359 

circumflex,  366 

facial,  359 

fifth,  360 

genito-crural,  369 

ilio-inguinal,  369 

laryngeal,  360 

median,  361 

motor-oculi,  360 

musculo-cutanecus,  371 

musculo-spiral,  365 

obturator,  368 

optic,  360 

peroneal,  370 

phrenic,  360 

pneumogastric,  360 

popliteal,  370 

radial,  365 

recurrent  laryngeal,  360 

sciatic,  369 

tibial  anterior,  371 
posterior,  372 

trifacial,  361 

ulnar,  362 
Noetzel,  wounds  of  spleen,  550 
Nose,  foreign  bodies,  454 

hemorrhage,  68 

Obstruction  of  bowel,  577 
Obturator  artery  ligation,  368 
dislocation,  333 


826 


INDEX 


Obturator  hernia,  strangulated,  628 

nerve,  368 
Occipital  artery  ligation,  720 
(Edema  of  the  glottis,  483 
CEsophagotomy,  484 
(Esophagus,  foreign  bodies,  455 

injuries,  87 
Ointment  of  Reclus,  471 
Olecranon,  fracture,  233 
Oliver,  strangulated  hernia,  617 

jaw  fracture,  310 
Omentum,  hemorrhage,  539 

resection,  645 

torsion,  674 
Open  wounds  of  thorax,  115 
Operation  in  private  houses,  6 
Operative  hemorrhage,  64 

wounds,  75 
Opium,  appendicitis,  563 
Optic  nerve  injury,  360 
Os  calcis,  Pirogoff 's  amputation,  769 

fracture,  281 
Oschner,  appendicitis,  564 

femoral  hernia,  645 

torsion,  670 
Osteomyelitis,  acute,  432 

femur,  438 

humerus,  437 

tibia,  435 
Ovarian  cysts,  torsion  of  pedicle,  667 

Pagenstecher,  linen,  25 
Palmar  abscess,  398 

arches,  66 
Panaris,  422 
Pancreas,  gunshot  wounds,  153 

injuries,  549 

suture,  549 
Pannett,  shell  wounds,  174 
Pantzer,  appendicitis,559 
Paracentesis,  ear-drum,  523 

pericardium,  498 

pleura,  504 
Paraphimosis,  790 
Parotid  gland  abscess,  382 


Patella,  dislocation,  336 

fracture,  264 

wiring,  266 
Peck,  wounds  of  heart,  497 
Pedicles,  ligation,  667 
Pelvic  abscess,  411 
Pelvis,  fractures,  297 
Penis,  injuries,  106 
Perborate  of  soda,  epistaxis,  70 
Peri-anal  abscess,  403 
Pericardiotomy,  500 
Pericardium,  paracentesis,  498 

puncture,  498 

suture,  490 

wounds,  122 
Perineal  abscess,  404 

bruises,  714 

section,  715 
Peritonitis,  purulent,  576 

treatment,  577 

typhoid,  576 

septic,  576 
Peroneal  nerve,  370 

tendons,  dislocation,  347 
Pfaff,  appendicitis,  562 

tubal  pregnancy,  679 
Phalanges,  fractures,  247 
Pharynx,  foreign  bodies,  455 
Phimosis,  wounds,  89 
Phlegmon,  421 

arm,  429 

fingers,  424 

forearm,  427 

neck,  429 

perineum,  714 

tendon  sheaths,  424 
Phrenic  nerve,  360 
Picric  acid,  burns,  471 
Piles  operation,  784 
Pinna,  wounds,  84 
Pirogoff's  amputation,  769 
Plantar  abscess,  400 
Plaster-of- Paris  bandages,  49 

Bavarian,  51 

preservation,  4 


INDEX 


827 


Plaster-of-Paris  splints,  50 
Pleura,  empyema,  509 

incision,  509 

puncture,  504 

wounds,  116 
Pneumogastric  nerve,  360 
Pneumothorax,  112 
Poisoned  wounds,  71 
Popliteal  abscess,  398 

artery  compression,  67 
Porter,  treatment  of  wounds,  78 
Posterior  nares,  plugging,  69 

tibial  artery,  726 
nerve,  372 
Post-operative  ileus,  586 
Potain's  aspirator,  504 
Pott's  fracture,  276 
Precordial  wounds,  122 
Pregnancy,  extra-uterine,  674 
Preparation,       emergency       opera- 
tions, 8 

hands,  9 

skin,  8 
Primary  hemorrhage,  57 
Probang,  foreign  bodies,  458 
Properitoneal  hernia,  614 
Prostatic  abscess,  404 
Psoas  abscess,  418 
Pulse,  abdominal  injury,  126 

appendicitis,    559 

chloroform  anesthesia,  13 

ether  anesthesia,  15 

hemorrhage,  58 

shock,  53 
Puncture,  bladder,  707 

knee-joint,  445 

pericardium,  498 

pleura,  504 

scrotum,  796 
Punctured  wounds,  76 
Purulent  pericarditis,  500 

pleurisy,  502 

Quadriceps    extensor    tendon,    rup- 
ture, 348 


Quenu,  preparation  of  room,  8 
Quinsy,  388 

Radial  artery,  compression,  67 
ligation,  723 

synovial  sheath  drainage,  424 
Radius,  fractures,  237 

gunshot,  160 

head,  236 

lower  end,  241 

neck,  236 

shaft,  238 
Ranzi,  torsions,  668 
Reclus,  lacerated  wounds,  100 

ointment,  471 
Rectal  injections,  581 
Rectum,  abscess,  403 

dilatation,  783 

foreign  bodies,  462 

hemorrhoids,  784 

wounds,  108 
Recurrent  laryngeal  nerve,  360 
Reduction  "en  masse,"  602 

dislocations,  313 

fractures,  204 

hernia,  601 
Removal  of  small  tumors,  804 
Resection  of  bowel,  651 
Respiratory  paralysis,  14,  15 
Responsibility     of    general    practi- 
tioner, 2 
Retention  of  urine,  698 
Retropharyngeal  abscess,  389 
Reverdin,  skin  grafting,  807 
Reynolds,  Cesarean  section,  684 
Ribs,  fracture,  295 

resection,  504 
Rinchea,  torsions,  674 
Ring-finger  amputation,  733 
Robinson,  shock,  56 
Romer,  fracture,  clavicle,  292 
Rongeur  forceps,  511 
Rossi,  fractures,  205 
Rosving,  appendicitis,  558 
Royster,  fracture  of  humerus,  220 


828 


INDEX 


Rubber  gloves,  lo 
Rugine,  506 

Rupture,  tubal  pregnancy,  675 
urethra,  686 

Saber  splint,  184 

Sacro-iliac  synchondrosis,  298 

Saline  solution  in  hemorrhage,  55 

sepsis,  574 
Sayres'  dressing,  291 
Scalds,  468 
Scalp,  abscesses,  379 

arteries,  66 

contusion,  81 

hematoma,  303 

wounds,  81 
Scapula,  amputations,  759 

fracture,  294 
Schaute,  Cesarean  section,  685 
Schleich's  formulae,  20 
Sciatic  nerv^e  injury,  369 
Sclerotic  wounds.  90 
Scrotum,  injuries,  106 
Scudder,  fracture  of  leg,  272 
Sebaceous  cysts,  removal,  804 
Secondar}^  hemorrhage,  57 
Semilunar  cartilages,  dislocation,  335 
Seminal  ducts,  abscess,  408 
Senn,  first  aid  on  battlefield,  179 

fracture  of  femur,  254 

hip-joint  amputation,  779 

intussusception,  584 
Septic  arthritis,  440 
Septum  nasi  abscess,  381 
Shaving  skin,  8 
Shell  wounds,  172 
Shock,  52 

diagnosis,  53 

treatment,  54 
Shoulder  amputation,  749 

arthrotomy,  448 

bandage,  45 

dislocations,  312 

fractures,  213 
Shrapnel  wounds,  172 


vSilk  sutures,  25 
Snkworm  sutures,  26 
Simons,  crushing  wounds,  99 
Skin  grafting,  807 

preparation,  10 
Skull,  bullet  wounds,  144,  167 

fracture,  base,  299 
compound,  303 
vault,  301 

trephining,  510 
Spence,  shoulder  amputation,  754 
Spermatic  cord,  ligation,  800 

torsion,  671 

vasectomy,  408 
Spica  for  breast,  44 

foot,  39 

groin,  41 

shoulder,  45 
Spinal  anesthesia,  22 

cord  injuries,  297 
Spine,  fractures,  296 

gunshot  wounds,  148,  170 

wounds,  104 
Spleen,  hemorrhage,  549 

injuries,  549 

removal,  550 

rupture,  550 

torsion,  615 
Splenectomy,  550 
Splint,  Bavarian,  51 

Dupuytren's,  277 

first  aid,  180 

Hodgen's,  262 
Splints,  48 

cradle,  164 

Dutch  cane,  48 

Gooch's,  48 

metal,  49 

plaster-of-Paris,  50 

silicate  of  potash,  48 

trough,  164 

wire  gauze,  49 

wooden,  48 
Sprains,  343 
St.  Andrew's  cross,  44 


INDEX 


829 


Stab  wounds,  76 

abdomen,  129 

heart,  425 

knee,  342 

thigh,  95 

thorax,  no 
Sterilization,  dressing,  7 

hands,  9 

instruments,  8 

skin,  10 
Stimson,  pain  in  fracture,  202 
Stomach,  hemorrhage,  152 

hernia,  617 

suture,  546 

wounds,  546 
Stewart,  suture  of  heart,  496 
Stovaine,  spinal  anesthesia,  22 
Strangulated  hernia,  598 

complications,  612 

diagnosis,  599 

femoral,  617 

inguinal,  603 

obturator,  628 

operation,  603 

taxis,  600 

umbilical,  622 
Stricture  of  urethra,  694 
Stump  bandage,  48 
Subclavian  artery,  compression,  66 

ligation,  720 
Subclavicular  dislocation,  316 
Subcoracoid  dislocation,  312 
Subcutaneous  wounds,  72 
Subcuticular  suture,  30 
Subglenoid  dislocation,  322 
Submammary  abscess,  395 
Submaxillary  abscess,  385 
Subphrenic  abscess,  414 
Subpubic  dislocation,  332 
Subspinous  dislocation,  324 
Suicide,  attempts,  186 
Superior  maxilla  fracture,  308 

thyroid  artery  ligation,  720 
Suprapubic  cystotomy,  695 

puncture,  707 


Surgical  dressings,  35 
Suture  of  arteries,  717 

bladder,  555 

heart,  495 

intestine,  543 

liver,  547 

lung,  490 

nerves,  357 

pancreas,  549 

tendons,  353 

ureter,  556 

wounds,  25 
Sutures,  catgut,  26 

continuous,  27 

horsehair,  25 

interrupted,  29 

Lembert,  544 

linen,  25 

methods  and  materials,  25 

Pagenstecher  linen,  26 

quilted,  25 

sero-serous,  543 

silk,  25 

silkworm-gut,  26 

subcuticular,  30 
Syme's  amputation,  770 
Syncope,  58 
Synovial  sheath  suppurations,  424 

cysts,  806 

Tampon     for     intercostal     hemor- 
rhage, 68 
Tapping,  hydrocele,  796 
Tarso-metatarsal,  amputation,  767 
Tarsus,  dislocations,  336 

fracture,  280 
Taxis,  indications,  600 

technic  femoral  hernia,  603 
inguinal  hernia,  601 
umbilical,  533,  603 
Taylor,  empyema,  502 

fracture  of  humerus,  221 
Temporal  artery  compression,  66 
Temporo-maxillary     joint     disloca- 
tion, 326 


830 


INDEX 


Tendon,  dislocations,  347 
divided,  351 
rupture,  347 
suture,  353 
wounds,  347 
Testis,  removal,  798 
suture,  107 
wounds,  107 
Tetanus,  bolo  wounds,  174 

Fourth-of-July  injvuies,  199 
prophylaxis,  199 
punctured  wounds,  76 
Thiersch,  skin  grafting,  808 
Thigh,  amputations,  777 

wounds,  95 
Thoracotomy,  indications,  488 

technic,  488 
Thorax,  injuries,  no 

open  wounds,  116 
Throat,  cut,  86 
Thrombosis,  lateral  sinus,  523 
Thumb,  amputations,  738 
bandage,  45 
dislocations,  329 
fracture,  247 
Tibia,  fractures,  270 
osteomyelitis,  435 
trephining,  436 
Tibial  arteries,  ligation,  725 

compression,  67 
Tillaux's  dressing,  258 
Toe-nail,  ingrowing,  801 
Toes,  amputation,  760 
Tongue,  abscess,  388 
suture,  85 
wounds,  85 
Tongue-traction,  asphyxia,  16 
Tonsil,  abscess,  388 
Torsion,  arteries,  62 
diagnosis,  667 
omentum,  674 
pedicle  ovarian  cysts,  667 
•     spleen,  673 
spermatic  cord,  671 
uterus,  669 


Townsend,  .    ciation,  699 

Toy-pistol  \\.    .1^,  198 
Trachea,  foreign  bodies,  459 

gunshot  wounds,  169 

incised  wounds,  88 
Tracheotomy,   after-treatment,    479 

foreign  bodies,  481 

indications,  477 

operations,  477 

tubes,  477 
Transfixion  apparatus,  162 
Travers,  suture  of  the  heart,  496 
Trephine,  Doyen,  514 

Gait,  514 
Trephining,  femur,  438 

fracture  of  skull,  510 

gunshot  wounds,  5:20 

humerus,  437 

tibia,  435 
Treves,  stangulated  hernia,  608 
Trunk  injuries,  no 
Tubal  pregnane}",  diagnosis,  675 

operation,  677 

rupture,  675 
Tuberctilar  abscess,  378 
Tuffier,  chest  wounds,  150 
Tumors,  superficial,  804 
Tunica  vaginaUs,  resection,  797 
Turpentine  burns,  471 
Tuttle,  imperforate  anus,  666 
Typhoid  perforation,  577 

Ulna,  fractures,  237 
Ulnar  arter^',  ligation,  724 

nerve  exposture,  362 
injury,  362 

synovial  sheath,  424 
Umbilical       hernia,       strangulated, 
622 

radical  cure,  550,  627 
Ureter,  repair,  556 

wounds,  556 
Urethra,  anatomy,  688 

catheterization,  695 

contusions,  689 


INDEX 


831 


Urethra,  foreig-  'odies,  465 

rupture  bulbous  portion,  690 
diagnosis,  687 
membranous  portion,  696 
pendulous  portion,  697 
symptoms,  688 
treatment,  690 
Urethral  forceps,  465 
Urethrotomy,  691 
Urgent  craniectomy,  510 

thoracotomy,  488 
Urinary  abscess,  712 
Urine,  extravasation,  712 

retention,  698 
Uterus,  torsions,  669 

Vagina,  abscess,  410 

injuries,  105 
Vagus  nerve,  360 

Valentine,    emergency    catheteriza- 
tion, 699 
Van       der       Walker,       emergency 

surgery,  6 
Van  Hook's  anastomosis,  556 
Vasectomy,  408 
Vaughn,  wounds  of  heart,  124 
Vault  of  skull  fracture,  301 

compound,  303 
Veins  of  liver,  ligation,  547 
Velpeau's  bandage,  290 
Venous  hemorrhage,  57 
Vincent,  trephining,  518 
Vineberg,  tubal  pregnancy,  676 
Vertebrae,  fractures,  296 
Viscera,  abdominal,  rupture,  126 
Volvulus,  579 
Von     Bergman,     gunshot     wounds, 

144 
Vulva,  wounds,  105 
Vulvar  abscess,  409 
Vulvo-vaginal  abscess,  410 

injuries,  105 

Wagner,  heart  injuries,  124 
Waite,  shock,  52 


Walker,  fractures  of  femur,  255 
Warbasse,    treatment    of    fraoture, 

205 
Wathen,  wounds  of  liver,  547 
Westmoreland,  tracheotomy,  478 
Whitehorne-Cole,  gunshot  wounds  of 

brain,  147 
Whitman,  fracture  of  femur,  255 
Wick  drains,  33 
Wire  gauze  splints,  49 
Wiring  fractured  fingers,  249 

olecranon,  233 

patella,  266 
Wooden  splints,  48 

trough  splint,  165 
Wounds,  abdomen,  128 

aseptic,  74 

base  of  thorax,  119 

bend  of  elbow,  95 

bladder,  554 

blank  cartridge,  199 

bolo,  173 

chest,  no 

cleansing,  79 

contused,  72 

definitions,  71 

diaphragm,  122 

drainage,  93 

dressings,  78 

elbow,  94 

esophagus,  89 

extremities,  92 

eye,  89 

eyelids,  85 

face,  84 

femoral  artery,  95 

fingers,  loi 

general  principles,  71 

gunshot,  civil,  186 
military,  133 

hand, 102 

head,  81 

heart,  122 

hemorrhage,  73 

incised,  73 


Wounds,  infected,  79 
intestine,  543 
kidney,  552 
lacerated,  76 
larynx,  88 
lips,  84 
liver,  546 
lung,  116 
neck,  86 
open,  71 
operative,  75 
pancreas,  549 
penis,  106 
pericardium,  122 
pharj'nx,  89 
pinna,  84 
pleura,  116 
precordial,  122 
punctured,  76 
rectum,  108 
scalp,  81 
scrotum,  106 
shell,  172 
special  regions,  81 
spine,  104 
spleen,  549 


Wounds,  stab,  76 

stomach,  546 

subcutaneous,  72 

suture,  26 

symptoms,  72 

testicle,  107 

thigh,  95 

thorax,  no 

tongue,  85 

toy  pistols,  199 

trachea,  88 

treatment,  70 

trunk,  no 

ureter,  556 

vagina,  105 

vulva,  105 

wrist,  92 
Wrist,  arthrotomy,  448 

dislocation,  340 

fractures,  246 

wounds,  92 

X-ray,  foreign  bodies,  457 
fractures,  203 

Zone  of  anesthesia,  19 


^  Oi'^Q 


%^ 


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